Review 2

A male client enters the oncology clinic for an evaluation. The nurse explains that the healthcare provider has ordered a prostate-specific antigen (PSA) test. The client asks the nurse, "How will this test tell if I have prostate cancer?" Which of the following is the nurse's best response?

"Individuals who have a PSA higher than 10 have a 60-70% chance of having prostate cancer."

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."

A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate?

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

Normal INR range

2-3

After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

30 minutes

Normal PaCO2

35-45

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority?

A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation.

A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs?

Abdomen

A nurse is assessing a client who has a history of a bleeding peptic ulcer. Which of the following assessments should the nurse report immediately?

Abdominal distension; cool, clammy skin; weak, thready pulse (Abdominal distension results from the increased blood in the stomach. Cool, clammy skin and a weak, thready pulse are signs of the body compensating after hemorrhage.)

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which of the following activities would be contraindicated?

Bending over the sink to wash the face. (because it increases intraocular pressure.)

Which condition may contribute to hyperparathyroidism?

Chronic renal failure (Because failing kidneys can't convert vitamin D, the serum calcium level declines. Parathyroid hormone release increases, causing hyperparathyroidism.)

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

Depriving the client of sufficient oxygen supply.

The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following?

Impaired skin integrity (Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection)

Following a total hip replacement, the nurse should position the client in which of the following ways?

Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.

The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:

Kussmaul's respirations. (The client with diabetic ketoacidosis exhibits Kussmaul respirations, as well as flushed skin, dry mouth, urinary frequency, and ketonuria)

The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is:

Lying down

A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:

Orange juice.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed (this position promotes comfort by decreasing pressure on the abdominal muscles)

The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage?

Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea (Increased pulse rate, a distended abdomen, and nausea signify the possibility of hemorrhage.)

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

Rest in an air-conditioned room. (- Lowering the body temperature by resting in an air-conditioned room may relieve fatigue)

After a laminectomy, the client states, "The physician said that I can do anything I want to." Which of the following client-stated activities indicates the need for further teaching?

Sweeping the front porch. (- Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture.)

The nurse teaches the client how to instill nose drops. Which of the following techniques is correct?

The client blows the nose gently before instilling drops.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume

While suctioning a client's laryngectomy tube, the nurse should insert the catheter:

Until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm).

A client is receiving digoxin. The pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should first:

Withhold the digoxin. (- The nurse's initial response should be to withhold the digoxin. The nurse should then notify the physician if the apical pulse is 60 bpm or lower because of the risk of digoxin toxicity)

To prepare the community for the possible threat of anthrax, a nurse must teach that:

anthrax can infect the integumentary, GI, and respiratory systems.

When educating the client with type 1 diabetes, the nurse knows that the client needs more education when he or she says:

"I will be able to switch to insulin pills when my sugar is under control."

Normal HCO3

22-26

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27% (According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.)

The nurse has an order to administer 2 oz of lactulose to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?

60 (- 30 mL = 1 oz)

normal ph

7.35-7.45

Normal PaO2

80-100

Normal calcium levels

9-10.5

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms (The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.)

What should a nurse do when administering pilocarpine?

Apply pressure on the inner canthus to prevent systemic absorption.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute (-Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses)

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

Normal Troponin

untraceable

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site (- indicates the presence of infection, at the left pin insertion site)

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

Assessing present voiding patterns

A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen?

Muscle spasms with paraplegia or quadriplegia from spinal cord lesions

When teaching a client when to take glipizide in order to maximize the effectiveness of the drug, the nurse should instruct the client to:

Take glipizide 30 minutes before breakfast. (Glipizide is most effective when taken 30 minutes before breakfast. The duration of action is 10 to 24 hours. If the drug needs to be taken more than once a day, the dosage may be divided and taken twice a day before meals)

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

• Reposition the client every 2 hours. • Perform range-of-motion exercises. • Encourage the client to eat a well-balanced diet.

A client with a new ileal conduit asks the nurse when he needs to wear his appliance. Which of the following responses by the nurse is correct?

"You need to wear your appliance all the time."

A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't answered immediately. What is the nurse's most appropriate response?

"You seem angry. Would you like to talk about it?"

During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following?

Atonic (During the period of spinal shock, the bladder is completely atonic and will continue to fill passively unless the client is catheterized.)

In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:

Bradyrhythmia (-Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope.)

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is:

Cardiac tamponade (Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest)

The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a:

Micron mesh filter. (- All blood products should be administered through a micron mesh filter)

The nurse is caring for a child with history of strep throat. Upon current assessment, the child states abdominal pain and joint achiness. Which laboratory data would the nurse communicate with the physician immediately?

Leukocytosis (Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. This finding is expected in a client with rheumatic fever.)

After teaching a client how to instill nose drops, the nurse evaluates that the client's technique is correct when the client does which of the following?

Lies supine for several minutes after instilling the drops.

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

Mafenide (- The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns)

Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?

Milk, apples, tomatoes, and corn.

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:

Moderate pain that worsens on inspiration.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Normal saline solution as this is considered an isotonic solution

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids (- To reduce water retention in a client with the SIADH, the nurse should restrict fluids)

The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?

Rigid abdominal wall. (- Diverticular rupture causes peritonitis from the release of intestinal contents (chemicals and bacteria) into the peritoneal cavity. A rigid abdominal wall results from a diverticular cavity. The inflammatory response of the peritoneal tissue produces severe abdominal rigidity and pain, diminished intestinal motility, and retention of intestinal contents (air, fluid, and stool)

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention. (Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal)

A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as:

fluid retention and weight gain.

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring?

Applying continuous-compression wraps (Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming)

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member, the monitor exhibits the following. Which interventions should the nurse do first?

Assess the client's airway, breathing, and circulation.

The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 ml less than was ordered for the day. The nurse should:

Assess the infusion system, note the client's condition, and notify the physician.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet. (- A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized)

The nurse is teaching a client with type I diabetes self-administration of insulin. Which statement by the client would be an expected outcome of the teaching session? Select all that apply.

• "I need to make sure that I eat my meals and snacks on time after I take my insulin." • "If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications." • "If I exercise more than is normal, there is a risk that I might become hypoglycemic."

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."

Normal WBC

4,500-10,000

Normal hematocrit

40-45% for men

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 urine output consistently above 40 ml/hour (40 mL/hour) (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)

A frail elderly client with a hip fracture is to use an alternating air pressure mattress to prevent pressure ulcers while recovering. The nurse is assisting the client's family to place the mattress (see accompanying image). The nurse should instruct the family to:

Make the bed with the bed sheet on top of the pressure mattress.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag (The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions)

A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH, 7.52; partial pressure of carbon dioxide, 38 mm Hg (5.1 kPa); bicarbonate, 34 mg/L (34 mmol/L). The nurse should plan care based on the fact that these findings indicate which of the following acid-base imbalances?

Metabolic alkalosis. (The pH of 7.52 indicates that the body is in a state of alkalosis. The partial pressure of carbon dioxide value is normal and the bicarbonate value is elevated. The increased bicarbonate value indicates that the acid-base imbalance is metabolic alkalosis. Restlessness can be a clinical finding in metabolic alkalosis.)

The nurse is collecting data on a client with a urinary tract infection (UTI). Which statements should the nurse expect the client to make? Select all that apply.

• "I need to urinate frequently." • "It burns when I urinate." • "I need to urinate urgently."

Which nursing interventions are effective in preventing pressure ulcers? Select all that apply.

• Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. • Turn and reposition the client every 1 to 2 hours unless contraindicated. • Use pillows to position the client and increase comfort.

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

• Elevate the head of the bed 15 to 30 degrees. • Contact the health care provider if ICP is greater than 20 mm Hg. • Monitor neurologic status using the Glasgow Coma Scale.