PrepU: Exam 3 Adults II Questions

A client is scheduled for a creatinine clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in: a. 1 minute. b. 30 minutes. c. 1 hour. d. 24 hours.

a. 1 minute rationale: The creatinine clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period.

Which drug is a vasodilator used in the treatment of shock? a. Dopamine b. Nitroglycerin c. Norepinephrine d. Dobutamine

b. nitroglycerin rationale: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.

A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is: a. renal calculi. b. an overdistended bladder. c. interstitial cystitis. d. acute prostatitis.

a. renal calculi rationale: Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuria.

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? a. Roll the client in a blanket b. Cover the client with a wet cloth c. Place the client with the head positioned slightly below the rest of the body d. Avoid immediate IV fluid therapy

a. roll the client in a blanket rationale: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

Which is defined as the potential of an agent to cause injury to the body? a. Volatility b. Latency c. Persistence d. Toxicity

d. toxicity rationale: The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? a. Blood urea nitrogen (BUN) level of 22 mg/dl b. Serum creatinine level of 1.2 mg/dl c. Temperature of 100.2° F (37.8° C) d. Urine output of 250 ml/24 hours

d. urine output of 250mL/ 24 hours rationale: ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

on the patients temple rationale: The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient's bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? a. Diphenhydramine (Benadryl) b. Pseudoephedrine (Sudafed) c. Guaifenesin (Robitussin) d. Loperamide (Imodium)

a. Diphenhydramine (Benadryl) rationale: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

Acetaminophen overdose is treated with administration of which medication? a. N-acetylcysteine b. Flumazenil c. Naloxone d. Diazepam

a. N- acetylcysteine rationale: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? a. A urine output consistently above 40 ml/hour b. A weight gain of 4 lb (2 kg) in 24 hours c. Body temperature readings all within normal limits d. An electrocardiogram (ECG) showing no arrhythmias

a. a urine output consistently above 40 ml/ hour rationale: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a. Administers oxygen by nasal cannula at 2 liters per minute b. Re-assesses the vital signs c. Contacts the admitting physician d. Calls the Rapid Response Team

a. administers oxygen by nasal cannula at 2 liters per minute rationale: The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

Which colloid is expensive but rapidly expands plasma volume? a. Albumin b. Dextran c. Lactated Ringer solution d. Hypertonic saline

a. albumin rationale: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate? a. "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." b. "You may discuss your prescriptions with your physician at your follow-up appointment." c. "If your temperature is normal for 48 hours, you may discontinue the medication." d. "The antibiotics will help the bone to heal."

a. antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury rationale: The nurse should tell the client that antibiotics are prescribed as a preventive measure for a client with a compound fracture because such fractures expose the bone to the environment and possible infection. Telling the client to discuss his medications with the physician at his follow-up appointment doesn't address the client's questions or immediate needs. The client needs this medication regardless of his body temperature. Antibiotics don't help a bone fracture to heal.

A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 mL. Urine output that's less than 50 ml in 24 hours is known as: a. oliguria. b. polyuria. c. anuria. d. hematuria.

a. anuria rationale: Urine output less than 50 ml in 24 hours is called anuria. Urine output of less than 400 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine.

The nurse recognizes the first dressing change at the site of an autograft is performed a. as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. b. within 12 hours after surgery. c. within 24 hours after surgery. d. as soon as sanguineous drainage is noted.

a. as soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery rationale: A foul odor or purulent drainage may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: a. blood pressure. b. hemoglobin level. c. temperature. d. heart rate.

a. blood pressure rationale: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with: a. botulism. b. anthrax. c. herpes. d. Ebola.

a. botulism rationale: A client with a mild to moderate case of botulism experiences dry mouth, double vision, unfocused vision, weakness, a sense of paralysis, and an unsteady gait. Anthrax symptoms include fever, flulike symptoms, cough, and a sore throat. Herpes isn't an agent of bioterrorism. Ebola symptoms include malaise, fatigue, headache, sore throat, and nausea.

A client develops acute renal failure (ARF) after receiving IV therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 mL, the nurse suspects that the client is at risk for: a. cardiac arrhythmia. b. paresthesia. c. dehydration. d. pruritus.

a. cardiac arrhythmia rationale: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.

A client who is blind is admitted for treatment of gastroenteritis. What does the nurse recognize as the highest priority for this client? a. Fluid volume deficit b. Risk for injury c. Activity intolerance d. Limited mobility

a. fluid volume deficit rationale: Because the client has gastroenteritis and is probably dehydrated, the client's fluid volume takes highest priority. A sensory deficit such as blindness puts the client at risk for injury from the environment; however, a potential problem doesn't take highest priority. Although the client's tolerance for activity and mobility also may be relevant, these don't take precedence over the client's dehydration.

What is the major clinical use of dobutamine? a. increase cardiac output. b. prevent sinus bradycardia. c. treat hypotension. d. treat hypertension.

a. increase cardiac output rationale: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? a. Kidney b. Ureter c. Bladder d. Urethra

a. kidney rationale: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess a. Lung sounds b. Skin perfusion c. Bowel sounds d. Mental status

a. lung sounds rationale: The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority? a. Monitor vital signs and oxygen saturation every 15 to 30 minutes. b. Suction the client as needed to obtain a sputum specimen for culture and sensitivity. c. Assess intake and output and maintain adequate hydration. d. Reassure the client that intubation and mechanical ventilation will be temporary.

a. monitor vital signs and oxygen saturation every 15 to 30 minutes rationale: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? a. Nitroprusside b. Dopamine d. Epinephrine d. Methoxamine

a. nitroprusside rationale: A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

Which finding is an early indicator of bladder cancer? a. Painless hematuria b. Occasional polyuria c. Nocturia d. Dysuria

a. painless hematuria rationale: Initially, as cancer cells destroy normal bladder tissue, bleeding occurs and causes painless hematuria. (Pain is a late symptom of bladder cancer.) Occasional polyuria may occur with diabetes mellitus or increased alcohol or caffeine intake. Nocturia commonly accompanies benign prostatic hypertrophy. Dysuria may indicate a urinary tract infection.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? a. Parasympathetic b. Sympathetic c. Endocrine d. Cerebral

a. parasympathetic rationale: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.

A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to a. Raise the head of the client's bed. b. Turn the client every 2 hours. c. Insert a rectal tube for decompression. d. Begin measurements of abdominal girth.

a. raise the head of the clients bed rationale: Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority.

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag? a. Red b. Yellow c. Green d. Black

a. red rationale: A client with a sucking chest wound is triaged as needing immediate care and would be tagged red. Clients with injuries that are significant and require immediate care but can wait hours without threat to life or limb would be tagged yellow. Clients with minor injuries would be tagged green. Clients with injuries that are extensive and whose chances of survival are unlikely even with definitive care are tagged black.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: a. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. b. a decreased serum phosphate level secondary to kidney failure. c. an increased serum calcium level secondary to kidney failure. d. metabolic alkalosis secondary to retention of hydrogen ions.

a. water and sodium retention secondary to severe decrease in the glomerular filtration rate rationale: The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address? a. "I've had diabetes for 4 years." b. "I'm allergic to shellfish." c. "I haven't eaten since midnight." d. "My physician diagnosed me with hypertension 3 months ago."

b. "Im allergic to shellfish" rationale: An allergy to iodine, shellfish, or other seafood should immediately be investigated because the contrast agent used in the procedure may contain iodine, which can cause a severe allergic reaction. Although contrast agents should be used cautiously in clients with diabetes mellitus, investigating this isn't the nurse's priority if the client also has a shellfish allergy. It's appropriate for the client to not eat after midnight before the procedure. The client's hypertension isn't a priority because this condition is the likely reason the renal angiography was ordered.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? a. A private room down the hall from the nurses' station b. An isolation room three doors from the nurses' station c. A semiprivate room with a client who has viral meningitis d. A two-bed room with a client who previously had bacterial meningitis

b. an isolation room three doors from the nurses station rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

Which type of shock occurs from an antigen-antibody response? a. Septic b. Anaphylactic c. Neurogenic d. Cardiogenic

b. anaphylactic rationale: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? a. Unstable angina pectoris b. Aortic insufficiency c. Hypertension d. Diabetes mellitus

b. aortic insufficiency rationale: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction? a. Apply heat to the fracture site. b. Apply ice to the fracture site. c. Perform ankle dorsiflexion three times per day. d. Use crutches for 1 week.

b. apply ice to the fracture site rationale: Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. Applying heat to the fracture site may increase swelling and bleeding. Ankle dorsiflexion has no therapeutic use after a toe fracture. It's unlikely the client would need crutches after a toe fracture.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed? a. Notify the physician of her findings immediately. b. Attend to the client's physiological needs. c. Notify the client's family. d. Notify the rape crisis team.

b. attend to the clients phsysiological needs rationale: The nurse should attend to the client's immediate physiological needs, including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete.

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation? a. The majority of clients arriving at the emergency department arrive by ambulance. b. Clients with Medicaid use the emergency department more often than clients with private health insurance. c. Heart attacks and stroke account for most of the visits to the emergency department. d. Clients, on average wait about a hour before being seen by a health care provider.

b. clients with medicaid use the emergency department more often than clients with private health insurance rationale: According to the most recent survey, clients with Medicaid use emergency departments more often than clients with private health insurance, Medicare, or self-pay. More than 15.5% of clients arrived at the emergency department by ambulance, leaving the majority of clients arriving by other means. Injuries account for almost one-half of all emergency department visits. The average emergency department waiting time before being seen by a health care provider for definitive treatment is approximately 2.4 hours.

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? a. Column A b. Column B c. Column C d. Column D

b. column b rationale: Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as a. Cardiogenic b. Compensatory c. Progressive d. Circulatory

b. compensatory rationale: The client's mentation, vital signs, and skin condition are those of a client in the compensatory stage of shock. Data are insufficient to support shock as either cardiogenic or circulatory in origin.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that: a. the client requires an antiviral agent. b. enteric precautions must be continued. c. enteric precautions can be discontinued. d. the client's infection may be caused by droplet transmission.

b. enteric precautions must be continued rationale: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? a. Compartment syndrome b. Fat embolism c. Infection d. Volkmann's ischemic contracture

b. fat embolism rationale: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? a. Hemoconcentration b. Hemodilution c. Metabolic acidosis d. Lack of erythropoietin factor

b. hemodilution rationale: Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? a. "Take your temperature every 4 hours." b. "Increase your fluid intake to 2 to 3 L per day." c. "Apply an antibacterial dressing to the incision daily." d. "Be aware that your urine will be cherry-red for 5 to 7 days."

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

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a. "Monitor urine output every hour." b. "Infuse I.V. fluids at 83 ml/hour." c. "Administer oxygen by nasal cannula at 3 L/minute." d. "Draw samples for hemoglobin and hematocrit every 6 hours."

b. infuse IV fluids at 83 ml/ hour rationale: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a. Do nothing until the chemical agent is identified. b. Irrigate the wounds with water. c. Wash the wounds with soap and water and apply a barrier cream. d. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

b. irrigate the wounds with water rationale: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the: a. lumbar spinal cord injury and lower extremity paralysis. b. maxillofacial injury and gurgling respirations. c. severe head injury and no blood pressure. d. second-trimester pregnancy in premature labor.

b. maxillofacial injury and gurgling respirations rationale: Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury? a. Life-threatening but survivable with minimal intervention b. Minor; treatment can be delayed hours to days c. Significant; injuries require medical care but can wait hours without threat to life or limb d. Extensive; chances of survival are unlikely even with definitive care

b. minor; treatment can be delayed hours to days rationale: A green triage tag (priority 3, or minimal) indicates injuries that are minor; treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care but can wait hours without threat to life or limb. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care.

Which positioning strategy should be used for a client diagnosed with hypovolemic shock? a. Supine b. Modified Trendelenburg c. Prone d. Semi-Fowler

b. modified trendelenburg rationale: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

A client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews his history for conditions that may warrant changes in client preparation. Normally, the client should be mildly hypovolemic (fluid depleted) before excretory urography. Which history finding calls for the client to be well hydrated? a. cystic fibrosis b. multiple myeloma c. gout d. myasthenia gravis

b. multiple myeloma rationale: Fluid depletion before excretory urography is contraindicated in clients with multiple myeloma, severe diabetes mellitus, and uric acid nephropathy — conditions that can seriously compromise renal function in fluid-depleted clients with reduced renal perfusion. If these clients must undergo excretory urography, they should be well hydrated before the test. Cystic fibrosis, gout, and myasthenia gravis don't necessitate changes in client preparation for excretory urography.

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as a. Hypovolemic b. Progressive c. Neurogenic d. Compensatory

b. progressive rationale: The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.

When describing the Emergency Operations Plan (EOP) to a group of nurses working as part of a disaster response team, which of the following would be identified as its primary goal? a. Coordinated response b. Protection of the community c. Threat level reduction d. Communication

b. protection of the community rationale: Although a coordinated response and communication are part of an EOP, its goal is the protection of the community. Threat level reduction is the purpose of preparedness, drill practice, training, security, and screenings.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse a. Elevates the head of the client's bed b. Raises the foot of the client's bed c. Turns the client to a side-lying position d. Places the client in a Trendelenburg position

b. raises the foot of the clients bed rationale: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a. Impaired urinary elimination b. Toileting self-care deficit c. Risk for infection d. Activity intolerance

b. risk for infection rationale: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock? a. Neurogenic b. Septic c. Cardiogenic d. Anaphylactic

b. septic rationale: Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with heart disease. Anaphylactic shock is associated with hypersensitivity reactions.

When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? a. The client sets the drainage bag on the floor while sitting down. b. The client keeps the drainage bag below the bladder at all times. c. The client clamps the catheter drainage tubing while visiting with the family. d. The client loops the drainage tubing below its point of entry into the drainage bag.

b. the client keeps the drainage bag below the bladder at all times rationale: To maintain effective drainage, the client should keep the drainage bag below the bladder; doing so allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because the bag could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

Which clinical finding should a nurse look for in a client with chronic renal failure? a. Hypotension b. Uremia c. Metabolic alkalosis d. Polycythemia

b. uremia rationale: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg b. Urine output of 20 ml/hour c. White pulmonary secretions d. Rectal temperature of 100.4° F (38° C)

b. urine output of 20ml/ hour rationale: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: a. hematuria. b. weight loss. c. increased urine output. d. increased blood pressure.

b. weight loss rationale: Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: a. apply maximum bandages to allow for absorption of drainage. b. wrap elastic bandages distally to proximally on dependent areas. c. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. d. remove bandages with clean gloves.

b. wrap elastic bandages distally to proximally on dependent areas rationale: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level? a. Stat b. 8 p.m. c. 11:00 p.m. d. 24 hours from the last dose

c. 11pm rationale: The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? a. Elevate the affected extremity. b. Contact the nursing supervisor. c. Administer oxygen. d. Contact the health care provider.

c. administer oxygen rationale: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the health care provider after administering oxygen.

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? a. Brachial artery b. Radial artery c. Aorta d. Right ventricular wall

c. aorta rationale: Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? a. Increased pH with decreased hydrogen ions b. Increased serum levels of potassium, magnesium, and calcium c. Blood urea nitrogen (BUN) 100 mg/dL and serum creatinine 6.5 mg/dL d. Uric acid analysis 3.5 mg/dL and phenolsulfonphthalein (PSP) excretion 75%

c. blood urea nitrogen (BUN) 100mg/dL and serum creatinine 6.5mg/dL rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. A BUN level of 100 mg/dl and a serum creatinine of 6.5 mg/dl are abnormally elevated results, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%.

Which complication is common for victims of electrical burns? a. Inhalation injury b. Infection c. Cardiac dysrhythmia d. Hypovolemic shock

c. cardiac dysrhythmia rationale: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: keep the client's knee on the affected side bent for 6 hours. apply pressure to the puncture site for 30 minutes. check the client's pedal pulses frequently. remove the dressing on the puncture site after vital signs stabilize. a. keep the client's knee on the affected side bent for 6 hours b. apply pressure to the puncture site for 30 mins c. check the clients pedal pulses frequently d. remove the dressing on the puncture site after vital signs stabilize

c. check the clients pedal pulses frequently rationale: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse should leave this dressing in place for several hours — and only remove it if instructed to do so.

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change? a. GI absorption rate b. Therapeutic index c. Creatinine clearance d. Liver function studies

c. creatinine clearance rationale: The physician should base changes to antibiotic dosages on creatinine clearance test results, which gauge the kidney's glomerular filtration rate; this factor is important because most drugs are excreted at least partially by the kidneys. The GI absorption rate, therapeutic index, and liver function studies don't help determine dosage change in a client with decreased renal function

When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? a. Deep partial thickness b. Superficial partial thickness c. Full thickness d. Superficial

c. deep partial thickness rationale: A deep, partial-thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: a. nausea and vomiting. b. dyspnea and cyanosis. c. fatigue and weakness. d. thrush and circumoral pallor.

c. fatigue and weakness rationale: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? a. "Be sure to eat meat at every meal." b. "Eat plenty of bananas." c. "Increase your carbohydrate intake." d. "Drink plenty of fluids, and use a salt substitute."

c. increase your carbohydrate intake rationale: A client with CRF requires extra carbohydrates to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.

A client suffering from carbon monoxide poisoning would exhibit which manifestation? a. Severe hypertension b. Hyperactivity c. Intoxication d. Cherry red skin coloring

c. intoxication rationale: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? a. Albumin b. Dextrose 5% in water (D5W) c. Lactated Ringer's solution d. Normal saline solution with 20 mEq of potassium per 1,000 ml

c. lactated ringers solution rationale: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? a. Encouraging coughing and deep breathing b. Promoting carbohydrate intake c. Limiting fluid intake d. Providing pain-relief measures

c. limiting fluid intake rationale: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and IV fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: a. planning for the client's rehabilitation and discharge. b. providing emotional support to the client and family. c. maintaining the client's fluid, electrolyte, and acid-base balance. d. preserving full range of motion in all affected joints.

c. maintaining the client's fluid, electrolyte, and acid base balance rationale: After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: a. limit oral fluid intake for 1 to 2 weeks. b. report the presence of fine, sandlike particles through the nephrostomy tube. c. notify the physician about cloudy or foul-smelling urine. d. report bright pink urine within 24 hours after the procedure.

c. notify the physician about cloud or foul smelling urine rationale: The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.

A nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point should the nurse include? a. Limit fluid intake to reduce the need to urinate. b. Take medication ordered for a UTI until the symptoms subside. c. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. d. Wear only nylon underwear to reduce the chance of irritation.

c. notify the physician if urinary urgency, burning, frequency, or difficulty occurs rationale: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. The client should notify the physician so that a microscopic urinalysis can be done and appropriate treatment can be initiated. The client should be instructed to drink 2 to 3 L of fluid per day to dilute the urine and reduce irritation of the bladder mucosa. To prevent UTI recurrence, the full amount of antibiotics ordered must be taken despite the fact that the symptoms may have subsided. Women are told to avoid scented toilet tissue and bubble baths and to wear cotton underwear, not nylon, to reduce the chance of irritation.

Exposure to gamma radiation can be decreased by completing which action? a. Wearing thick clothes b. Lengthening the duration of exposure c. Providing distance from radiation source d. Providing plastic shielding

c. providing distance from radiation source rationale: Gamma radiation can penetrate clothing and skin. Thick clothes do not provide any kind of protection. Lead blocks radiation, but it is safest to limit exposure and to distance oneself from the source.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? a. Use standard precautions, which require gloves for suctioning. b. Put on gloves, a mask, and eye protection. c. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. d. Take no special precautions for this client.

c. put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the clients face for transport rationale: Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.

Which condition or laboratory result supports a diagnosis of pyelonephritis? a. Myoglobinuria b. Ketonuria c. Pyuria d. Low white blood cell (WBC) count

c. pyuria rationale: Pyelonephritis is diagnosed by the presence of pyuria, leukocytosis, hematuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Myoglobinuria is seen with any disease process that destroys muscle. Ketonuria indicates a diabetic state. Because the client with pyelonephritis typically has signs of infection, the WBC count is more likely to be high rather than low

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? a. Do nothing because the nurse has no proof of wrongdoing. b. Monitor the situation during subsequent visits. c. Report the suspicion to the local agency on aging within 24 hours of the visit. d. Try to convince the client to report the problem.

c. report the suspicion to the local agency on aging within 24 hours of the visit rationale: The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.

When a client is in the compensatory stage of shock, which symptom occurs? a. Bradycardia b. Urine output of 45 mL/hr c. Tachycardia d. Respiratory acidosis

c. tachycardia rationale: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

What is a common source of airway obstruction in an unconscious client? a. A foreign object b. Saliva or mucus c. The tongue d. Edema

c. the tongue rationale: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

Which statement reflects the nursing management of pulmonary anthrax (Bacillus anthracis)? a. Airborne person-to-person transmission occurs with anthrax. b. Diagnosis is done by pulmonary function testing and chest x-ray. c. Treatment with ciprofloxacin or doxycycline is suggested after exposure. d. Pulmonary effects include respiratory failure, shock, and death within 5 to 7 days after exposure.

c. treatment with ciprofloxacin or doxycycline is suggested after exposure rationale: Treatment is with ciprofloxacin or doxycycline because recommended because these easily given oral antibiotic agents are stockpiled and there should be sufficient dosages to fully treat many clients who have been anthrax-exposed. Anthracis is a spore-forming bacteria resulting in gastrointestinal, pulmonary, and skin symptoms. Symptoms are dependent upon contact, ingestion, or inhalation of the spores. Routine universal precautions are effective. Anthrax survives in the spore form for long periods making the body a potential source of infection for morticians. Blood cultures are required to confirm the bacteria's presence and diagnosis. The pulmonary effects include respiratory failure, shock, and death within 24 to 36 hours after exposure.

A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: a. with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. b. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. c. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. d. who is experiencing mild pain from urolithiasis.

c. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. rationale: A sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L in a client immediately following dialysis should be the priority assessment. Pinkish mucus discharge in the appliance bag is a normal finding for a client who's had an ileal conduit, as are a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L in a client who's had a kidney transplant. Although the nurse should further assess mild pain from urolithiasis, this is an expected finding and not a priority in relation to the client with abnormal sodium and potassium levels.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? a. 18% b. 27% c. 30% d. 36%

d. 36% rationale: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? a. Keep the AV fistula site dry. b. Keep the AV fistula wrapped in gauze. c. Take the client's blood pressure in the left arm. d. Assess the AV fistula for a bruit and thrill.

d. assess the AV fistula for a bruit and thrill rationale: The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.

A client requires hemodialysis. Which type of drug should be withheld before this procedure? a. Phosphate binders b. Insulin c. Antibiotics d. Cardiac glycosides

d. cardiac glycosides rationale: Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

During the acute phase of a burn, a nurse should assess: a. the client's lifestyle. b. alcohol use. c. tobacco use. d. circulatory status.

d. circulatory status rationale: During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.

The nurse is caring for a client diagnoses with severe acute respiratory syndrome (SARS). A family member asks what causes SARS. Which response by the nurse is accurate? a. Escherichia coli b. Salmonella c. shigella d. Coronavirus

d. coronavirus rationale:

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? a. Precompensatory b. Compensatory c. Progressive d. Irreversible

d. irreversible rationale: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? a. Cranberry juice b. Coffee c. Prune juice d. Milk

d. milk rationale: A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? a. Poor perfusion to the kidneys b. Damage to cells in the adrenal cortex c. Obstruction of the urinary collecting system d. Nephrotoxic injury secondary to use of contrast media

d. nephrotoxic injury secondary to use of contrast media rationale: Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure.

A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed: a. on protective isolation. b. on neutropenic precautions. c. in a negative-pressure room. d. on contact isolation.

d. on contact isolation rationale: C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. A nurse who is in direct contact with the client should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/?l or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which C. difficile diarrhea is not.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: a. fluid resuscitation. b. infection. c. body image. d. pain management.

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

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a. Refractory b. Compensatory c. Irreversible d. Progressive

d. progressive rationale: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? a. Related to fat emboli b. Related to infection c. Related to femoral artery occlusion d. Related to circumferential eschar

d. related to circumferential eschar rationale: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)? a. Acyclovir is effective against smallpox. b. Smallpox is spread by inhalation of spores. c. A vaccination is effective only if administered within 12 to 24 hours of exposure. d. Smallpox spreads rapidly and requires immediate isolation.

d. smallpox spreads rapidly and requires immediate isolation rationale: Smallpox is spread by droplet or direct contact. No antiviral agents are effective against smallpox; however, vaccination within 2 to 3 days of exposure is protective. In 4 to 5 days, vaccination may prevent death and should be administered with vaccinia immune globulin. Smallpox spreads rapidly and requires immediate isolation. Even in death, the disease can be transmitted.

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? a. Encourage oral fluids. b. Administer furosemide (Lasix) 20 mg IV c. Start hemodialysis after a temporary access is obtained. d. Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

d. start IV fluids with a normal saline solution bolus followed by a maintenance dose rationale: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find: a. distended jugular veins. b. hypothermia. c. hypertension. d. tachycardia.

d. tachycardia rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? a, The client's serum sodium levels are elevated. b. The client exhibits metabolic alkalosis. c. The client's urinary output has fallen below 30 ml/hour. d. The client's complete blood count readings reflect a reduced hematocrit.

d. the clients complete blood count readings reflect a reduced hematocrit rationale: During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? a. Serum potassium level of 4.9 mEq/L b. Serum sodium level of 135 mEq/L c. Temperature of 99.2° F (37.3° C) d. Urine output of 20 ml/hour

d. urine output of 20mL/ hour rationale: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.