RN Adult Medical Surgical Online Practice 2023 B

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ? mL/hr

167 mL/hr Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 4,000 mL Step 3: What is the total infusion time? 24 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL)X mL/hr = Time (hr) 4,000 mLX mL/hr = 24 hr X mL/hr = 166.67 Step 6: Round if necessary. 166.67 = 167 mL/hr Step 7: Determine if the amount to administer makes sense. If the prescription reads 2,000 kcal to infuse over 24 hr, it makes sense to administer 167 mL/hr. The nurse should set the IV pump to deliver TPN IV at 167 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 4,000 mLX mL/hr = 24 hr Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 4,000 mLX mL/hr = 24 hr Step 4: Solve for X. X mL/hr = 166.67 Step 5: Round if necessary. 166.67 = 167 mL/hr Step 6: Determine if the amount to administer makes sense. If the prescription reads 2,000 kcal to infuse over 24 hr, it makes sense to administer 167 mL/hr. The nurse should set the IV pump to deliver TPN IV at 167 mL/hr.

A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. 1200: - Prepare client for exploratory laparotomy - Gentamicin 100 mg IV - Keep client NPO except medications Which of the following actions should the nurse take? Select the 3 actions that the nurse should take. A. Give detailed explanation of the operative procedure. B. Provide the client with high-flow supplemental oxygen. C. Administer client's PO medication with a sip of water. D. Check for shellfish allergy. E. Administer gentamicin 100 mg IV. F. Shave the client's abdominal and pelvic area. G. Ensure that the client has provided informed consent.

Answer: C. Administer client's PO medication with a sip of water. E. Administer gentamicin 100 mg IV. G. Ensure that the client has provided informed consent. Rationale: - When taking actions after reviewing the client's EMR and provider prescriptions, the nurse should prepare the client for an exploratory laparotomy by ensuring that the client has provided informed consent, administer gentamicin 100 mg IV, and the client's prescribed PO phenytoin. The client has findings of peritonitis in which the provider evaluating further.

The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. Nurses' Notes: A. Client is short of breath and has a productive cough with yellow mucus. B. "I could barely breathe when I got up this morning and I had a throbbing headache." C. Capillary refill less than 2 seconds. D. Client is diaphoretic. E. Crackles heard in posterior lungs. F. Pedal pulses +2 bilaterally.

Answer: - Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. - "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem. - Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a potential problem. - Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the expected reference range and indicates adequate perfusion. - Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem. - Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected reference range and indicates adequate perfusion.

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ? mL

Answer: 24 mL Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 5 mLX mL = 125 mg Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL600 mgX mL = × 125 mg1 Step 4: Solve for X. X mL = 24 mL Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If there are 125 mg/5 mL and the prescription reads 600 mg, it makes sense to administer 24 mL. The nurse should administer phenytoin oral solution 24 mL PO.

The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. A. WBC count - 15,000/mm3​ (5,000 to 10,000/mm3) B. Temperature - 38.6° C (101.5° F) C. Potassium level - 5.4 mEq/L (3.5 to 5 mEq/L) D. Heart rate - 88/min E. Oxygen saturation - 97% on 2 L/min of oxygen via nasal cannula

Answer: A, B, C A - The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. B - The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing intervention. C - The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention. Rationale: D - The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. E - The nurse should identify the client's oxygen saturation has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention.

The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. Nurse's Notes Day 5 0800: A. Heart rate 72/min B. Respiratory rate 20/min C. Blood pressure 128/56 mm Hg D. Oxygen saturation 95% on room air E. Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation. F. Cough is productive with yellow mucus.

Answer: A, B, C, D - The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. - The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving. Rationale: E - The nurse should identify that the client's lungs sounds are still diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. F - The client's cough is still productive with yellow mucus due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving.

BUN 24 mg/dL (10 to 20 mg/dL) Chest x-ray reveals increased opacity in the bilateral posterior lobes. Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL) HCO3-​ 24 mEq/L (22 to 26 mEq/L) Oxygen saturation 88% on room air PCO2 50 mm Hg (35 to 45 mm Hg) WBC count 12,000/mm3 (5,000 to 10,000/mm3) The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. (Select All that Apply.) A. BUN level B. Chest x-ray C. Calcium level D. HCO3- level E. Oxygen saturation level F. PCO2 level G. WBC count

Answer: A, B, E F, G PCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse.

A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. A. "I will be sure to ask for pain medication before my knee starts to hurt too bad." B. "Well, I guess there's no changing my mind about having surgery now." C. "I will need to do the breathing exercises every 1 to 2 hours after the surgery." D. "I will probably be going home with a walker." E. "My physical therapy will start after I leave the hospital."

Answer: A, C, D A - For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe. C - The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. D - It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery. Rationale: B - The nurse and the client reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any time. E - Early ambulation leads to improved postoperative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The client should be informed that physical therapy will begin the day of, or the day following, surgery.

A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include? Select all that apply. A. Avoid highly seasoned foods. B. Eat five servings of fresh fruit per day. C. Consume high-protein snacks. D. Avoid drinking fluids with meals. E. Eat several small meals per day. F. Maintain a high carbohydrate intake.

Answer: A, C, D, E A - The nurse should instruct the client to avoid excessive amounts of spices and salt. C - The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome. D - The nurse should instruct the client to drink fluids 30 min before or after meals. E - The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day. Rationale: B - The client should limit intake to three servings of unsweetened cooked or canned fruit per day. F - Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia.

Click to highlight the findings that require follow-up. Client with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small all amount of blood in the stool, and a [A - 12% weight loss over the past 2 months.] Client's weight 2 months ago was 100.3 kg (221.1 lb). Client has a [B - history of Crohn's disease and a seizure disorder that is managed with diet and medication.] Abdominal assessment performed with [C- muscle guarding and tenderness in the right lower quadrant] noted on palpation. [D - Abdomen is firm and rigid] upon examination. [E - Abdominal pain rated as an 8 on a scale of 0 to 10.] Client states that pain is constant and localized in the lower right abdominal quadrant. [F - Reports anorexia.] [G- Hypoactive bowel sounds] noted upon auscultation. [H - Temperature 38.5° C (101.4° F)] [I - Blood pressure 136/78 mm Hg] [J - Oxygen saturation 97% on room air]

Answer: A, C, D, E, F, G, H When recognizing cues, the nurse should identify the assessment findings that require follow-up include 12 % weight loss over 2 months, muscle guarding and tenderness in right lower quadrant of abdomen, abdominal firmness and rigidity, abdominal pain rate of 8, hypoactive bowel sounds, report of anorexia and temperature of 38.5 C (101.4 F) require follow up by the nurse. These are unexpected findings that should be assessed further by the nurse and may require further intervention.

Day 50800: Discharge to home Follow up with provide within 1 week Hydrocodone/acetaminophen 10 mg/325 mg PO every 4 hr PRN pain Daily dressing changes for closed incisionMonitor temperature daily Notify provider of manifestations of infection Nurse to provide teaching to client following laparotomy procedure and peritonitis A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.) A. "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit." B. "I will pack my abdominal wound with gauze after cleaning it." C. "I should avoid taking vitamin supplements." D. "I should schedule several rest periods throughout the day." E. "I should alternate taking acetaminophen with my prescribed pain medication."

Answer: A, D - When evaluating outcomes, the nurse should identify that the client understands discharge teaching after stating "I will schedule several rest periods throughout the day" and "I will notify my provider if temperature is greater than 101 F." The client had an exploratory laparotomy procedure and has a closed incision; therefore, the client will require rest throughout the day and should monitor for manifestations of infection such as an elevated temperature and drainage from surgical wound.

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet? A. 12 almonds B. One small banana C. 1 tbsp peanut butter D. 1/2 cup tomato juice

Answer: A. 12 almonds - The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia. Rationale: B - The nurse should recommend a different food because there is another choice that contains more calcium. One small banana contains 5 mg of calcium. C - The nurse should recommend a different food because there is another choice that contains more calcium. One tbsp of peanut butter contains 8 mg of calcium. D - The nurse should recommend a different food because there is another choice that contains more calcium. A half cup of tomato juice contains 12 mg of calcium.

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A. A client who is receiving preoperative teaching for a right knee arthroplasty. B. A client who states they will have difficulty obtaining a walker for home use. C. A client who reports an increase in pain following a left hip arthroplasty. D. A client who is having emotional difficulty accepting that they have a prosthetic leg.

Answer: A. A client who is receiving preoperative teaching for a right knee arthroplasty. - The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. Rationale: B - The nurse should make a referral to a social worker for a client who reports difficulty obtaining a walker for home use. C - The nurse should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty. D - The nurse should refer the client to a counselor to assist with coping with the adjustment to the need of a prosthetic leg.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? A. Document that depolarization has occurred. B. Increase the pacemaker's voltage. C. Decrease the pacemaker's sensitivity. D. Check the placement of the ECG leads.

Answer: A. Document that depolarization has occurred. - When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization. Rationale: B - The presence of a QRS complex after the spike indicates that the pacemaker has adequate voltage to stimulate the heart. C - Sensitivity should be decreased if the pacemaker fires at a regular rate in the presence of an adequate intrinsic rhythm, which is not the case for this client. D - A pacing stimulus followed by a QRS complex indicates the pacemaker is firing correctly. The ECG leads are detecting this activity and do not need to be checked.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? A. Drink 240 mL (8 oz) of water after administration. B. Expect results in 4 to 6 hr. C. Take this medication before meals to increase appetite. D. Reduce dietary fiber intake to improve medication absorption.

Answer: A. Drink 240 mL (8 oz) of water after administration. - The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid. Rationale: B - The client should expect results in 12 to 24 hr and bowel regularity in 2 to 3 days. C - The client should take the medication after meals to prevent appetite suppression. D - Reducing dietary fiber intake does not affect medication absorption. However, the client should increase dietary fiber intake for management of chronic constipation.

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? A. Heart rate 110/min B. Blood pressure 160/70 mm Hg C. Respiratory rate 14/min D. Temperature 38.4° C (101.1° F)

Answer: A. Heart rate 110/min - One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss. Rationale: B - An early sign of hemorrhage is a slight increase in the diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An increase in blood pressure postoperatively can indicate that the client is in pain. C - An increase in the respiratory rate from the client's baseline is an indication of hemorrhage. D - An increase in temperature from the client's baseline is an indication of infection, not hemorrhage.

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? A. History of Asthma B. Appendectomy 1 year ago C. Penicillin allergy D. Total knee arthroplasty 6 months ago

Answer: A. History of Asthma - A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate. Rationale: B - A history of an appendectomy does not have an effect on a CT scan. However, clients who have a history of diabetes mellitus, renal impairment, or heart failure have an increased risk for renal failure when contrast media is used and require further screening. C - A penicillin allergy does not have an effect on a CT scan. However, a client who is taking certain medications, such as aminoglycosides, NSAIDs, and the biguanide metformin, is at increased risk for renal damage and requires further screening. D - A total knee arthroplasty does not have an effect on a CT scan.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. B. Assist the client to start arm exercises 48 hr after surgery. C. Maintain the right arm in an extended position at the client's side when in bed. D. Place the client in a supine position for the first 24 hr after surgery.

Answer: A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. - The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period. Rationale: B - The nurse should instruct the client to start exercising the right arm 24 hr after surgery. C - The nurse should elevate the client's right arm on a pillow to promote lymphatic fluid return. D - The nurse should elevate the head of the client's bed to at least 30° to promote drainage from the surgical site and facilitate breathing.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? A. Keep a lead-lined container in the client's room. B. Limit each visitor to 1 hr per day. C. Place a dosimeter badge on the client. D. Remove soiled linens from the client's room each day.

Answer: A. Keep a lead-lined container in the client's room. - The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant. Rationale: B - The nurse should restrict each visitor to 30 min per day to limit exposure to radiation. C - The nurse and other facility staff should wear a dosimeter badge when in the client's room to monitor their exposure to radiation. D - The nurse should keep all soiled linens in the client's room until the client has had the radiation implant removed.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Low urine specific gravity B. Hypertension C. Bounding peripheral pulses D. Hyperglycemia

Answer: A. Low urine specific gravity - An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone. Rationale: B - The nurse should expect a client who has diabetes insipidus to have hypotension due to dehydration caused by excessive excretion of urine. C - The nurse should expect a client who has diabetes insipidus to have weak peripheral pulses due to dehydration caused by excessive excretion of urine. D - Hyperglycemia is a manifestation of diabetes mellitus. Manifestations of diabetes insipidus include polydipsia and polyuria.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? A. Nonrebreather mask B. Venturi mask C. Simple face mask D. Partial rebreather mask

Answer: A. Nonrebreather mask - The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask. Rationale: B - The nurse should initiate a Venturi mask for a client who requires an exact oxygen flow. A Venturi mask can only deliver an oxygen concentration between 24% and 50%. C - The nurse should initiate a simple face mask for a client who requires short-term supplemental oxygen. A simple face mask can only deliver an oxygen concentration between 40% and 60%. A simple face mask does not usually fit well and can lead to skin breakdown. D - The nurse should initiate a partial rebreather mask for a client who can sustain adequate oxygen saturation levels with a mixture of room air and oxygen. A partial rebreather allows a portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to a range between 60% and 75%.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion. B. Prime the blood administration IV tubing with lactated Ringer's solution. C. Verify the client's identity by using the client's room number prior to starting the transfusion. D. Infuse the unit of packed RBCs within 8 hr.

Answer: A. Remain with the client for the first 15 min of the infusion. - The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood. Rationale: B - The nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or hemolysis of the RBCs. C - The client's room number is not an acceptable client identifier. The nurse should ensure that the name and number on the client's identification band matches the name and identification number on the blood label. The client's identification, the blood compatibility, and the expiration date of the blood should be verified by two nurses. D - The nurse should transfuse the packed RBCs within 2 to 4 hr based upon the client's age and cardiovascular status. Longer infusion times increase the risk for bacterial contamination of the blood product.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? A. Report of sore throat B. Report of memory loss C. Alopecia D. Mucositis

Answer: A. Report of sore throat - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis. Rationale: B - Report of memory loss is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse's priority. The nurse should provide the client with cognitive training strategies to reduce memory loss. C - Alopecia is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is nurse's the priority. The nurse should instruct the client to cover their head to protect from injury due to sunburn or loss of heat. D - Mucositis is nonurgent because it is an expected finding for a client who is receiving chemotherapy; therefore, there is another finding that is the nurse's priority. The nurse should instruct the client to increase water intake and use a soft toothbrush to reduce mucositis.

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. B. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy. C. Family members should follow airborne precautions at home. D. A follow-up tuberculosis skin test is necessary in 2 months.

Answer: A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. - After three negative sputum cultures, the client is no longer considered infectious. Rationale: B - The client's infection is usually no longer contagious after taking TB medications for 2 to 3 weeks. C - Family members do not need to follow airborne precautions because they have already been exposed to TB. D - A follow-up evaluation of the client's TB should be performed using a chest x-ray because the TB skin test is no longer considered accurate after a person has tested positive.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? A. Suction machine B. Wire cutters C. Padded clamp D. Communication board

Answer: A. Suction Machine - The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration. Rationale: B - The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary fixation to cut the wires in case the client vomits. This enables the client to clear their airway and reduce the risk for aspiration. C - The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to clamp the tube and prevent air from entering the client's chest if there is an interruption in the sealed drainage system. D - The nurse should ensure a communication board is at the bedside of a client who has aphasia to assist the client with communicating.

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? A. Try to walk at least three times per week for exercise. B. To increase stamina, walk for 5 min after fatigue begins. C. Take over-the-counter cough medicine for persistent cough. D. Use a salt substitute to reduce sodium intake.

Answer: A. Try to walk at least three times per week for exercise. - The development of a regular exercise routine can improve outcomes in clients who have heart failure. Rationale: B - Walking for 5 min after the onset of fatigue will not increase stamina and can exacerbate the client's heart failure. C - The provider should approve the use of over-the-counter cough medication for a persistent cough prior to use. A persistent cough can exacerbate the client's heart failure. D - Salt substitutes contain an increased amount of potassium, which can place the client at an increased risk for hyperkalemia.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? A. Wear a mask. B. Wear a gown. C. Keep the client's room well-lit. D. Maintain the head of the bed at a 45° elevation.

Answer: A. Wear a mask - Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. Rationale: B - A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis does not spread via direct contact. C - Staff caring for this client should keep the illumination in the room dim and avoid bright light from windows to promote comfort and rest and avoid photophobia. D - Staff caring for this client should keep the head of the bed at a 30° elevation

After reviewing the findings in the client's medical record, the nurse should first address the client's (weight loss/abdominal findings/heart rate) followed by the client's (anorexia/pain rating/hemoglobin level)

Answer: After reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING - When prioritizing hypotheses and using the priority framework of urgent vs non-urgent approach to client care, the nurse first should address the client's abdominal findings followed by the client's pain rating. Abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. The nurse should next address the client's pain rate of 8 which indicates moderate pain which requires intervention by the nurse.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) A. Expressive aphasia B. Visual spatial deficits C. Left hemianopsia D. Right hemiplegia E. One-sided neglect

Answer: B, C, E B - Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. C - Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. E - One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke. Rationale: A - Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke. D - One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take calcium supplements so the medication will work better in my system." B. "I am taking this medication to increase my energy level." C. "This medication can cause my blood pressure to drop." D. "I will not need to restrict protein in my diet while taking this medication."

Answer: B. "I am taking this medication to increase my energy level." - The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. Rationale: A - A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal. C - Therapy with erythropoietin increases RBC production, which can result in hypertension, not hypotension. D - Erythropoietin does not affect the client's protein requirements, but the client should continue to restrict protein as prescribed by the provider to manage kidney disease.

A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching? A. "I will avoid eating raw fruits and vegetables." B. "I can ask a friend to change my cats litter box." C. "I will use a mild soap when washing my genital area." D. "I can sip on a glass of juice for at least 2 hours before I should discard it."

Answer: B. "I can ask a friend to change my cats litter box." - Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's litter box. Rationale: A - The nurse should instruct the client to wash raw fruits and vegetables thoroughly prior to eating them, because uncleaned fruits and vegetables can contain micro-organisms and place the client at risk for an infection. C - The nurse should instruct the client to wash genital area twice a day with anti-microbial soap to prevent bacterial and fungal infections. D - The nurse should instruct the client to avoid drinking any liquids that have been out for more than 1 hr. Beverages left out for extended periods of time could expose the client to micro-organisms and place them at risk for an infection.

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? A. "It is just easier to let my partner administer my insulin." B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." C. "I'm concerned I won't be able to read my blood sugar level because the screen is so small." D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."

Answer: B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." - This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications. Rationale: A - This statement does not indicate that the client is successfully coping with the change. C - This statement does not indicate that the client is successfully coping with the change. The nurse should provide the client with a monitor that has a larger screen. D - This statement does not indicate that the client is successfully coping with the change.

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I will wash the ink markings off the radiation area after each treatment." B. "I will use my hands rather than a washcloth to clean the radiation area." C. "I will be able to be out in the sun 1 month after my radiation treatments are over." D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy."

Answer: B. "I will use my hands rather than a washcloth to clean the radiation area." - The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. Rationale: A - The ink markings designate the exact radiation area. The client should not remove these markings until they complete the entire radiation treatment. C - Radiation therapy causes skin to become sensitive to the effects of sun exposure and increases the risk for developing skin cancer. The client should avoid direct sunlight during the radiation treatments and for at least 1 year following the conclusion of the therapy. D - The client should avoid exposing the treatment area to heat as this can cause further irritation to the skin.

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? A. Encourage the client to eat raw fruits and vegetables. B. Avoid placing plants or flowers in the client's room. C. Limit visitors to members of the client's immediate family. D. Wear an N95 respirator mask when providing care to the client.

Answer: B. Avoid placing plants or flowers in the client's room. - Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. Rationale: A - The nurse should identify that P. aeruginosa can be found in raw fruits and vegetables. C - The nurse does not need to limit visits to family members. However, the nurse should prohibit visits from those at risk for P. aeruginosa infection, such as anyone who is ill, other hospitalized clients, and small children. D - P. aeruginosa spreads by contact, either on health care workers' hands or contaminated equipment. It is not airborne, so respirator masks are unnecessary.

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? A. Obtain a sputum specimen to determine if there is colonization. B. Bathe the client using chlorhexidine solution. C. Place the client in droplet isolation. D. Restrict visits from the client's friends and family.

Answer: B. Bathe the client using chlorhexidine solution. - The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body. Rationale: A - The nurse should obtain a nasal specimen to determine if there is colonization of MRSA. C - The nurse should place the client in contact isolation to decrease the risk of the spread of MRSA. D - The nurse does not need to restrict the client's visitors. The nurse should instruct the client's friends and family to wear gowns and gloves when visiting the client to decrease the risk of the spread of MRSA.

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? A. Inspect the cast for drainage once every 24 hr. B. Check that one finger fits between the cast and the leg. C. Perform neurovascular checks every 2 to 3 hr. D. Make sure the client has a warm blanket covering the cast.

Answer: B. Check that one finger fits between the cast and the leg. - To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. Rationale: A - The nurse should inspect the cast for drainage and alignment at least once every 8 to 12 hr. C - For the first 24 hr after cast application, the nurse should check the neurovascular status of the client's leg every hour. The nurse does this by assessing sensation, motion, and circulation. D - The nurse should make sure the cast is uncovered to allow for thorough air drying of the plaster. Also, the heat that is generated by the drying process has to escape.

Weight 67.1 kg (148 lb) SaO2 92% 1+ pedal edema Heart rate 55/min Digoxin 0.25 mg PO dailyFurosemide 40 mg PO dailyPotassium chloride 20 mEq/L PO daily Sodium 135 mEq/L (136 to 145 mEq/L) Potassium 4.1 mEq/L (3.5 to 5 mEq/L) Digoxin 1.8 ng/dL (0.8 to 2 ng/dL) Laboratory ResultsDischarge:Sodium 137 mEq/L (136 to 145 mEq/L)Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Digoxin 1.2 ng/dL (0.8 to 2 ng/dL)Current:Sodium 135 mEq/L (136 to 145 mEq/L)Potassium 4.1 mEq/L (3.5 to 5 mEq/L)Digoxin 1.8 ng/dL (0.8 to 2 ng/dL) A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? A. Potassium 4.1 mEq/L B. HR 55/min C. SaO2 92% D. Weight 67.1 (148 lb)

Answer: B. HR 55/min - The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. Rationale: A - The client's potassium level of 4.1 mEq/L is within the expected reference range (3.5 to 5 mEq/L). C - The nurse should ensure that the client's SaO2 level remains at or above 90%. This finding is within the expected reference range. D - The nurse should report a client's weight gain of 1.4 kg (3 lb) in a day or 2.3 kg (5 lb) or more in a week.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. Painless ulcerations on the ankles B. Hair loss on the lower legs C. No extremity pain when resting D. Rubor with elevation of the extremity

Answer: B. Hair loss on the lower legs - The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth. Rationale: A - The nurse should expect a client who has peripheral arterial disease to have painful ulcerations on the ends of toes and between the toes as a result of impaired arterial circulation. C - The nurse should expect a client who has peripheral arterial disease to have pain when resting as a result of the outflow of the blood in the lower extremities when at rest. This pain is relieved by dangling the lower extremities off a bed. D - The nurse should expect a client who has peripheral arterial disease to have dependent rubor, which is redness as a result of dangling or ambulation.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? A. INR 1 (0.8 to 1.1) B. INR 2.5 (0.8 to 1.1) C. aPTT 45 seconds (30 to 40 seconds) D. aPTT 90 seconds (30 to 40 seconds)

Answer: B. INR 2.5 (0.8 to 1.1) - Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation. Rationale: A - INR, along with PT, is obtained to measure the clotting abilities of the blood in a client who is taking warfarin. This INR value is below the target reference range for a client who has atrial fibrillation. C - Clients who are receiving heparin should have aPTT levels monitored to ensure appropriate anticoagulation is achieved. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds. D - aPTT is obtained to measure the clotting abilities of the blood. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds.

A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? A. Take an antacid before meals and at bedtime. B. Increase fiber intake to at least 30 g per day. C. Drink ginger tea daily. D. Consume no more than 1 L of water per day.

Answer: B. Increase fiber intake to at least 30 g per day. - Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns. Rationale: A - Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and pain associated with diarrhea and constipation. Anticholinergic or antispasmodic agents can be prescribed to control cramping. C - Ginger tea is useful for treating nausea, not cramping. Additionally, a client who has IBS should avoid dairy products, raw fruits, and grains that can cause bloating. D - The client should consume at least 2 L of water daily to promote regular bowel function.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? A. Administer a placebo to the client without their knowledge. B. Instruct the client on alternative therapies for pain reduction. C. Tell the client not to worry about addiction to prescribed narcotics. D. Suggest the client receive a different opioid for pain reduction.

Answer: B. Instruct the client on alternative therapies for pain reduction. - The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction. Rationale: A - The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights. C - This response by the nurse is nontherapeutic because it dismisses the client's concerns. D - By suggesting the client receive a different opioid for pain reduction, the nurse is disregarding the client's concerns about opioid use disorder.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A. Remove the client's indwelling urinary catheter. B. Irrigate the indwelling urinary catheter. C. Clamp the indwelling urinary catheter. D. Apply traction to the indwelling urinary catheter.

Answer: B. Irrigate the indwelling urinary catheter. - The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow. Rationale: A - The nurse should not remove the client's indwelling urinary catheter as it ensures adequate urine flow. C - Clamping the urinary catheter can increase pressure inside the client's bladder and cause internal bleeding. D - The nurse should apply traction to the catheter to reduce the risk for bleeding, but this action will not clear the tubing of an obstruction.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? A. Defibrillate the client's heart. B. Perform synchronized cardioversion. C. Begin cardiopulmonary resuscitation. D. Administer lidocaine IV bolus.

Answer: B. Perform synchronized cardioversion - Perform synchronized cardioversion.The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia. Rationale: A - The nurse should defibrillate the client's heart for ventricular tachycardia or ventricular fibrillation. C - The nurse should initiate CPR for a client who is pulseless or not breathing. D - The nurse should administer lidocaine IV bolus for a client who has a ventricular dysrhythmia.

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? A. Explain procedures as they occur to the client. B. Place personal items, such as pictures, at the client's bedside. C. Orient the client to their location once a shift. D. Encourage the family members to remain home until the client has adjusted.

Answer: B. Place personal items, such as pictures, at the client's bedside. - The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support. Rationale: A - The nurse should plan to explain all procedures and routines to the client before they occur to decrease confusion and anxiety. C - The nurse should plan to orient the client to person, place, and time frequently during a shift to decrease confusion and anxiety. D - The nurse should plan for family members and friends to visit often to decrease confusion and anxiety and to reinforce cognitive support.

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? A. Document the client's intake and output. B. Scan the bladder with a portable ultrasound. C. Pour warm water over the client's perineum. D. Perform a straight catheterization.

Answer: B. Scan the bladder with a portable ultrasound. - The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder. Rationale: A - The nurse should document the client's intake and output to ensure adequate fluid balance. However, there is another action that the nurse should take first. C - Pouring warm water over the client's perineum is a method for stimulating micturition. However, there is another action that the nurse should take first. D - Performing a straight catheterization might prove necessary. However, there is another action that the nurse should take first.

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I should avoid walking as much as possible." B. "I should sit down and read for several hours a day." C. "I will wear clean graduated compression stockings every day." D. "I will keep my legs level with my body when I sleep at night."

Answer: C. "I will wear clean graduated compression stockings every day." - The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand. Rationale: A - A client who has venous insufficiency should maintain an exercise regimen, such as routine walking, to decrease venous stasis. B - A client who has venous insufficiency should avoid sitting or standing for prolonged periods of time due to the risk of developing deep-vein thrombosis or skin breakdown. D - A client who has venous insufficiency should elevate the legs above heart level while in bed to facilitate venous return and avoid venous stasis.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. "I will need to take antibiotics for 1 year." B. "My partner will need to take an antiviral medication." C. "My joints ache because I have Lyme disease." D. "I bruise easily because I have Lyme disease."

Answer: C. "My joints ache because I have Lyme disease." - Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue. Rationale: A - A client who has severe stage II Lyme disease will be prescribed a 30-day course of antibiotics. The nurse should emphasize to the client that, like with other types of infection, the full course of antibiotics should be completed. B - Lyme disease is a vector-borne illness that is treated with antibiotics. Other vector-borne illnesses, such as West Nile Virus, are treated with antiviral medications. Lyme disease is not transmitted to others via human contact. D - Lyme disease is an infectious disease that affects the body systemically, involving the neurologic, musculoskeletal, and cardiac systems. Cardiac manifestations include carditis and dysrhythmias. However, a client who has stage II Lyme disease does not typically experience bruising.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? A. "This measures how much blood my heart is pumping." B. "This identifies if I have a defective heart valve." C. "This identifies if the pacemaker cells of my heart are working properly." D. "This measures the blood circulating to my heart muscle."

Answer: C. "This identifies if the pacemaker cells of my heart are working properly." - Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle. Rationale: A - Cardiac output, which is calculated by multiplying heart rate and stroke volume, measures the amount of blood ejected by the heart over 1 min. B - An echocardiogram, a noninvasive ultrasound procedure, evaluates heart valve function and structure. D - Cardiac catheterization allows for the measurement of coronary artery blood flow.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? A. "You will still have the urge to void." B. "You can apply an aspirin tablet to the pouch to reduce odor." C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." D. "You should use a moisturizing soap when washing the skin around the stoma."

Answer: C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." - The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine. Rationale: A - During the procedure, the client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma, from which urine will flow into an external ostomy bag. Therefore, the client will not have an urge to void. B - The client should not add an aspirin tablet to the pouch, because it can ulcerate the stoma. D - The client should avoid using moisturizing soaps to clean the skin around the stoma because it will prevent the pouch from adhering to the skin.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? A.Restlessness B. T3 level 215 ng/dL (40 to 180 ng/dL) C. Blood pressure 170/80 mm Hg D. Decreased weight

Answer: C. Blood pressure 170/80 mm Hg - Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm. Rationale: A - Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. B - An elevated T3 level is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. D - Decreased weight is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? A. The chest tube is draining serosanguineous fluid at 65 mL/hr. B. The client tolerates gentle milking of the tubing. C. Bubbling in the water seal chamber has ceased. D. There is tidaling in the water seal chamber.

Answer: C. Bubbling in the water seal chamber has ceased. - Bubbling in the water seal chamber ceases when the lung re-expands. Rationale: A - Serosanguineous drainage of 65 mL/hr is an expected finding for the client but does not indicate lung re-expansion. B - The nurse can gently milk the chest tube to release clots, but the client's ability to tolerate this action does not indicate lung re-expansion. D - The presence of tidaling in the water seal chamber results from the client's inhalation and exhalation and is not indicative of lung re-expansion.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? A. Ginkgo biloba B. Glucosamine C. Calcium D. Vitamin C

Answer: C. Calcium - Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. Rationale: A - Ginkgo biloba reduces the pain associated with peripheral vascular disease by promoting vasodilation. It can interact with medications that have anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine. B - Glucosamine treats osteoarthritis by decreasing inflammation and stimulating the body's production of synovial fluid and cartilage. It can interact with medications that have antiplatelet or anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine. D - Vitamin C promotes wound healing. It can cause a false negative in fecal occult blood tests, but it is not known to interfere with the absorption of levothyroxine.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? H/P: Gouty arthritis for 3 years Hypertension diagnosed 5 years ago1 pack per day cigarette use for 15 yearsFamily history of prostate cancer Lab Results: Blood glucose (fasting) 102 mg/dL (74 to 106 mg/dL)BUN 15 mg/dL (10 to 20 mg/dL)Creatinine 1 mg/dL (0.5 to 1.1 mg/dL)Prostate Specific Antigen (PSA) 1.5 ng/mL (0 to 2.5 ng/mL) Prescriptions: Ibuprofen PRN for headaches Olmesartan 20 mg PO daily Prednisone 5 mg PO daily A. Disease processes B. Laboratory findings C. Current medications D. Family history

Answer: C. Current medications - The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing. Rationale: A - A history of gout and hypertension will not affect the results of the allergy skin testing. When reviewing a client's health record, the nurse should identify a history of diseases that alter the immune response as an interfering factor that can cause false negative results. B - The client's laboratory values are within the expected reference ranges and are not an indication for postponing allergy skin testing. D - Allergy skin testing results can be affected by age; infants and older adult clients can have decreased reactivity to allergens. However, family history is not a factor in consideration for postponing allergy skin testing.

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A. Oral Candidiasis (Thrush) B. Dry Oral Mucous Membrane/Tongue with Deep Furrows C. Glossitis D. Healthy tongue

Answer: C. Glossitis - This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. Rationale: A - This image depicts oral candidiasis, or thrush, which is an overgrowth of yeast (Candida albicans) in the mouth, which results in a yellowish-white coating on the surface of the tongue. B - This image depicts a dry oral mucous membrane and tongue, with deep furrows on the surface of the tongue that indicate dehydration. D - This image depicts a healthy tongue that is dull red in color and moist with a slightly rough anterior surface.

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following results is an indication of an adverse effect of the medication? A. Increased potassium B. Increased magnesium C. Increased BUN D. Increased hematocrit

Answer: C. Increased BUN - Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result. Rationale: A - Amphotericin B can cause damage to the kidneys and cause hypokalemia. B - Amphotericin B can cause several metabolic imbalances, including hyponatremia, hypokalemia, and hypomagnesemia. D - Amphotericin B can cause bone marrow suppression and, as a result, a decreased hematocrit.

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? A. Monitor the client's INR daily. B. Expel air bubbles when using a prefilled syringe. C. Inject the medication into the anterolateral abdominal wall. D. Massage the injection site after administration.

Answer: C. Inject the medication into the anterolateral abdominal wall. - The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation. Rationale: A - A client who is taking enoxaparin does not require a daily INR. The nurse should periodically compare the client's CBC with a baseline CBC. B - The nurse should plan to follow the injection of the medication with the air bubble located at the site of the plunger in the prefilled syringe. The air bubble ensures that the client receives the whole dose of the medication. D - The nurse should avoid massaging the client's injection site after administration to minimize bruising.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? A. Obtain ABGs. B. Administer propofol to the client. C. Instruct the client to allow the machine to breathe for them. D. Disconnect the machine and manually ventilate the client.

Answer: C. Instruct the client to allow the machine to breathe for them. - When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." Rationale: A - The nurse should monitor ABG results to determine the effectiveness of mechanical ventilation, but this is not the first action the nurse should take. B - The nurse might need to administer propofol to provide sedation and increase the client's tolerance of mechanical ventilation, but this is not the first action the nurse should take. D - Many factors can cause a high-pressure alarm to sound. The nurse might have to disconnect the machine and manually ventilate the client if the ventilator fails or the client experiences respiratory distress, but this is not the first action the nurse should take.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? A. Bounding pedal pulse B. Capillary refill less than 2 seconds C. Pain that increases with passive movement D. Areas of warmth on the cast

Answer: C. Pain that increases with passive movement - The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight. Rationale: A - The nurse should expect a client who has compartment syndrome to have a diminished pulse or pulselessness in the affected extremity due to lack of distal perfusion caused by a decrease in the muscle compartment size. B - The nurse should expect a client who has compartment syndrome to have capillary refill greater than 2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a decrease in the muscle compartment size. D - A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an infection of the underlying tissue, not compartment syndrome.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? A. Use pillows to support the client's head and neck. B. Offer opioid medication. C. Place a tracheostomy tray at the bedside. D. Place the client in semi-Fowler's position.

Answer: C. Place a tracheostomy tray at the bedside. - The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction. Rationale: A - The nurse should use pillows to support the client's head and neck to prevent stress on the suture line, but this action is not the priority. B - The nurses should offer opioid medication for pain relief, but this action is not the priority. D - The nurse should place the client in semi-Fowler's position to avoid neck extension, but this action is not the priority.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? A. Keep the client's personal care items in the bathroom. B. Keep the overhead lights on in the client's bedroom while the client is sleeping. C. Remind the client to scan their complete range of vision during ambulation. D. Secure the client's extension cords under carpeting.

Answer: C. Remind the client to scan their complete range of vision during ambulation. - The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. Rationale: A - The nurse should instruct the client's family to keep the client's personal care items within the client's reach to reduce the risk for falls. B - The nurse should instruct the family to use nightlights in the client's bedroom and bathroom to reduce the risk for falls. Keeping the overhead lights on while the client is sleeping can disrupt the client's circadian rhythm. D - The nurse should instruct the client's family that they should secure extension cords to the client's baseboards using electrical tape, rather than placing them under carpeting. This practice can help to reduce the risk for falls.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? A. Hyperreflexia B. Increased blood pressure C. Respiratory paralysis D. Tachycardia

Answer: C. Respiratory paralysis - The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. Rationale: A - Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of magnesium sulfate. B - Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension. D - Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? A. Elevated blood pressure B. Dehydration C. Stress ulcers D. Hypernatremia

Answer: C. Stress Ulcers - Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment. Rationale: A - Positive pressure from mechanical ventilation inhibits blood return to the heart, leading to decreased cardiac output and hypotension. B - Decreased cardiac output associated with mechanical ventilation places the client at risk for fluid retention. D - Hyponatremia can occur secondary to fluid retention that results from long-term mechanical ventilation.

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing? A. Weight loss of 1 kg in 1 week B. BMI 24 C. Urine output 25 mL/hr D. Report of 3/10 pain on a 0 to 10 pain scale

Answer: C. Urine output 25 mL/hr - Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. Rationale: A - A decrease in weight of 4.54 kg (10 lb) in a short time period is a sign of a nutritional problem, which can delay wound healing. B - BMI readings provide a means of determining a client's nutritional status. Clients who have a BMI less than 18.5 are considered at risk for complications, such as poor wound healing. D - A well-managed pain level enhances a client's willingness to increase mobility.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? A. Secure the straps firmly around the boot. B. Remove the device before showering. C. Use crutches with rubber tips. D. Adjust the screws to maintain alignment.

Answer: C. Use crutches with rubber tips. - Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls. Rationale: A - The surgeon applies the external fixation device directly to the client's bone to form a rigid structure around the affected extremity. Casts, boots, or splints are applied to the leg for internal fixation. B - The client should wear external fixation devices continuously for a period of 4 to 6 weeks. The nurse should teach the client to perform care of the wound and pin sites at home. D - Only the provider should adjust the client's external fixation device to maintain bone alignment.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take my iron with a glass of milk." B. "I will take an antacid with my iron." C. "I will limit my intake of red meat." D. "I will eat more high-fiber foods."

Answer: D. "I will eat more high-fiber foods." - The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements. Rationale: A - Although oral iron supplements can cause gastrointestinal disturbances, the client should not consume dairy products at the same time as taking iron because dairy products inhibit the absorption of iron. B - Although oral iron supplements can cause gastrointestinal disturbances, the client should not take antacids at the same time as taking iron because antacids inhibit the absorption of iron. C - The client should increase intake of red meat because red meat is high in iron and will supplement this medication.

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my toothbrush in the dishwasher once a month." B. "I should eat more fresh fruit and vegetables." C. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." D. "I will take my temperature once a day."

Answer: D. "I will take my temperature once a day." - A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection. Rationale: A - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should clean their toothbrush weekly in the dishwasher or in a bleach solution to destroy micro-organisms. B - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid eating raw fruits and vegetables that can contain bacteria and cause infection. The nurse should advise the client to eat a low-bacteria diet. C - A client who has AIDS is immunocompromised and is at risk for infection. Therefore, the client should avoid drinking a glass of liquid that stands for 60 min or more to reduce the risk of drinking contaminated liquids.

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A. Electrically generated feelings of heat B. Cryotherapy for painful areas C. Realignment of energy flow through meridians D. A tingling sensation replacing the pain

Answer: D. A tingling sensation replacing the pain - A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain. Rationale: A - A TENS unit does not create heat when applied to a painful area. Warm compresses, heating pads, and paraffin dips are examples of modalities that apply heat to painful areas. B - Many over-the-counter gels and creams work by creating a sense of cold to help relieve muscles aches and pain. A TENS unit does not work by cryotherapy, or cold treatment. C - Acupuncture is a therapy that works via the insertion of fine needles to help unblock any obstructed flow of energy in other parts of the body. A TENS unit does not clear obstructions in energy flow.

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A. Apply ice to the client's puncture wounds. B. Initiate corticosteroid therapy for the client. C. Keep the client's leg above heart level. D. Administer an opioid analgesic to the client.

Answer: D. Administer an opioid analgesic to the client. - The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. Rationale: A - The nurse should apply ice for a bite from a black widow spider to reduce the action of the neurotoxin from the spider. B - The nurse should expect a prescription for antihistamines and corticosteroids for stings from bees and wasps. C - The nurse should keep the affected extremity at heart level, not above or below it.

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? A. Shellfish B. Peanuts C. Eggs D. Avocados

Answer: D. Avocados - Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. Rationale: A - Clients who have a shellfish allergy might have an allergic reaction to povidone-iodine. B - Clients who have a peanut allergy might have an allergic reaction to propofol. C - Clients who have an egg allergy might have an allergic reaction to propofol.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? A. Hypotension B. Tachypnea C. Nuchal rigidity D. Bradycardia

Answer: D. Bradycardia - BradycardiaA client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure. Rationale: A - A client who has increased intracranial pressure from a traumatic brain injury can develop hypertension, which is one component of Cushing's triad. B - A client who has a traumatic brain injury can develop decreased cerebral blood flow, which results in increased arterial pressure. The changes to arterial pressure cause changes in blood pressure. However, respirations are not affected. C - Nuchal rigidity, or neck stiffness, is an indication of meningitis.

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? A. Position tabletop clocks with multi-colored backgrounds throughout the home. B. Explain how to complete a task while having the client do the task. C. Place a calendar on the wall with days and weeks included. D. Create complete outfits and allow the client to select one each day.

Answer: D. Create complete outfits and allow the client to select one each day. - The family should place completed outfits on hangers and allow the client to select which one to wear each day. Rationale: A - The family should use easy-to-read clocks with a plain background to minimize confusion and allow the client to find and read them easily. B - The family should explain how to complete a task before there is a need to complete the task to minimize confusion and frustration. C - The family should place a calendar on the wall with the present day available to view to minimize confusion and assist in orientation.

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A. Decreased T cells B. Increased creatinine clearance C. Increased eosinophils D. Decreased viral load

Answer: D. Decreased viral load - Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment. Rationale: A - T cells are responsible for cellular immunity. The T cell count indicates the body's ability to fight opportunistic infections and cancer. A decreased T cell count indicates the progression of HIV. Once the T cell count falls below 200 cells/mm3, the client receives a diagnosis of AIDS. B - Creatinine clearance measures the ability of the kidneys to filter the blood. An increased creatinine clearance level indicates compromised renal function, which is a common occurrence in clients who have HIV. C - Eosinophils are a type of leukocyte that are responsive to parasitic infections and allergic reactions. An increase in eosinophils indicates the presence of infection.

A nurse is caring for an client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? A. Check on the client every 2 hr. B. Provide a quiet environment with no distractions. C. Turn on the television in the client's room. D. Keep the client occupied with a manual activity.

Answer: D. Keep the client occupied with a manual activity. - The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter. Rationale: A - The nurse should check on the client at least once every hour. B - The nurse should provide soft music to calm the client. If possible, the nurse should allow the client to choose the type of music they prefer. C - If the client is agitated, the nurse should turn off the television in the client's room.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? A. Metoprolol B. Bupropion C. Atorvastatin D. Naproxen

Answer: D. Naproxen - Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. Rationale: A - Metoprolol does not interact with feverfew. B - Bupropion does not interact with feverfew. C - The nurse should recognize that the effect of atorvastatin is decreased by St. John's wort.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? A. 240 mL (8 oz) of orange juice B. 1 ampule of 50% dextrose IV bolus C. NPH insulin 60 units subcutaneous D. Regular insulin 20 units IV bolus

Answer: D. Regular insulin 20 units IV bolus - DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously. Rationale: A - DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Orange juice would increase the client's blood glucose levels. B - DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. An ampule of 50% dextrose would increase the client's blood glucose levels. C - NPH insulin is a long-acting insulin with an onset of 1.5 to 4 hr. The treatment goal for a client who has DKA is to reduce the blood glucose level 50 to 75 mg/dL every hour, which requires the nurse use a faster-acting insulin.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Rebound abdominal tenderness D. Tachycardia

Answer: D. Tachycardia - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider. Rationale: A - Anorexia is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. B - Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. C - Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority.

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? A. Avoid foods that are high in ascorbic acid. B. Add oatmeal to the water when taking a tub bath. C. Urinate every 6 hr. D. Take daily cranberry supplements.

Answer: D. Take daily cranberry supplements. - The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI. Rationale: A - A client who is at risk for developing UTIs should increase intake of ascorbic acid to acidify the urine. B - A client who is at risk for developing UTIs should take showers rather than tub baths because bacteria in the bath water can enter the urethra. C - A client who is at risk for developing UTIs should urinate every 2 to 4 hr.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? A. Total cortisol 0.9 mcg/dL (5 to 23 mcg/dL) B. Amylase 440 units/L (30 to 220 unit/L) C. Calcium 7.5 mg/dL (9 to 10.5 mg/dL) D. Troponin I 8 ng/mL (less than 0.03 ng/mL)

Answer: D. Troponin I 8 ng/mL (less than 0.03 ng/mL) - Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred. Rationale: A - A total cortisol level of 0.9 mcg/dL is less than the expected range. However, a decreased level of cortisol indicates a deficiency of the adrenal, pituitary, or thyroid glands, not an MI. B - An amylase level of 440 units/L is above the expected range. However, an increased amylase level indicates pancreatitis, not an MI. C - A calcium level of 7.5 mg/dL is below the expected range. However, a decreased calcium level indicates a condition such as renal failure, hypoparathyroidism, or vitamin D deficiency, not an MI.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? A. Blood sodium level 132 mEq/L (136 to 145 mEq/L) B. Forearm skin tents when pinched C. Respiratory rate decreased D. Urine specific gravity 1.045 (1.005 to 1.03)

Answer: D. Urine specific gravity 1.045 (1.005 to 1.03) - A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. Rationale: A - A client who has hypertonic dehydration may experience a blood sodium level above the expected reference range because the kidneys would respond to loss of free body water by attempting to conserve the free body water which increases the blood concentration of sodium. A finding of 132 mEq/L is below the expected reference range and indicates an excess of free body water. B - Skin turgor can be an unreliable indication of dehydration in older adult clients because of age-related changes to skin elasticity. The nurse should check an older adult client's skin turgor on the sternum, rather than on the limbs, for a more reliable indicator. C - The nurse should expect the client's respiratory rate to increase if dehydration occurs because the decreased vascular fluid volume seen with dehydration decreases oxygenation and organ perfusion, requiring a compensatory increase in the respiratory rate.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? A. Hydrocodone B. Bupropion C. Lactulose D. Warfarin

Answer: D. Warfarin - Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery. Rationale: A - Hydrocodone is an opioid analgesic and is not contraindicated for a client scheduled for eye surgery. However, long-term opioid use can alter the client's response to analgesic agents. B - Bupropion is an antidepressant and is not contraindicated for a client scheduled for eye surgery. C - Lactulose is a laxative to treat constipation and is not contraindicated for a client scheduled for eye surgery.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? A. Change the dressing every 72 hr. B. Immobilize the hand with a pressure dressing. C. Take pain medication 30 min after changing the dressing. D. Wrap fingers with individual dressings.

Answer: D. Wrap fingers with individual dressings - The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand. Rationale: A - The nurse should instruct the client to change the dressing every 12 to 24 hr to allow for wound inspection. The client should observe the wound closely for manifestations of increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection. B - A client who undergoes surgery to receive skin grafts for full-thickness burns should elevate and immobilize the graft site with cotton pressure dressings for 3 to 5 days following the procedure. This action prevents the graft from dislodging and allows for revascularization of the wound. C - The nurse should instruct the client to take pain medication 30 min before a dressing change to decrease the level of pain during the procedure.

A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Click to highlight the findings the nurse should report to the provider immediately. A. Client sleeping, arouses to verbal stimuli B. Respiratory rate 14/min C. Oxygen saturation 95% on room air, breath sounds clear D. Reports pain as 2 on scale of 0 to 10 E. Perineal pad saturated with blood, large clots present F. Change of blood pressure, heart rate of 102/min

Answer: E, F - The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider. Rationale: ABCD - These are expected findings. Therefore, the nurse does not need to report these findings to the provider.

1200: Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are expectorating pink-tinged mucus. Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion noted. Neck veins flat. No peripheral edema observed. Blood pressure 136/90 mm Hg Respiratory rate 32/min Temperature 38.7° C (101.6° F) Heart rate 110/min SaO2 90% on 3 L/min via nasal cannula The client is most likely experiencing _________ and__________. A. Pnuemonia B. Pneumothorax C. Fluid Volume Overload D. Acute Chest Syndrome

Answer: The client is most likely experiencing PNEUMONIA and ACUTE CHEST SYNDROME D - The client is most likely experiencing acute chest syndrome, which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain. A - The client is most likely experiencing pneumonia as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain. Rationale: C - While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein distension, and hypertension. B - While the client is experiencing increased respiratory distress, a pneumothorax typically presents with reduced or absent breath sounds and unequal chest expansion.

Oxygen saturation 88% on room air Client reports decreased appetite for the past 2 days. BUN 24 mg/dL (10 to 20 mg/dL) Temperature 38.6° C (101.5° F) Heart rate 98/min Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." The nurse should first address the client's (Oxygen Saturation/Loss of Appetite/BUN level) followed by the client's (Heart Rate/Temperature/Headache)

Answer: The nurse should first address the client's OXYGEN SATURATION followed by the client's TEMPERATURE - The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. - The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate. Rationale: - Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. - BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. - Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. - Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first.

Client presents with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7/ 10. Client also reports N/V and dyspepsia. Client is A&O x3. Lung sounds clear B/L S1 and S2. Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L) ALT 39 international units/L (4 to 36 international units/L) LDH 200 units/L (100 to 190 units/L) WBC count 12,000/mm3 (5,000 to 10,000/mm3) Potential Conditions: - Cholecystitis - Appendicitis - Ulcerative colitis - Peritonitis Actions to Take: - Maintain the client in semi-Fowler's position. - Administer morphine IV. - Place the client on bed rest. - Ensure the client is NPO. - Insert an NG tube. Parameters to Monitor: - Monitor the client for rectal bleeding. - Monitor the color of the client's stools. - Monitor for pain at McBurney's point. - Monitor the client for a rigid, board-like abdomen. - Monitor the client for dark urine.

Answer: The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Initiate IV therapy with a large-bore catheter B. Administer oxygen via a nonrebreather mask C. Insert an NG tube D. Administer Famotidine

Answer:. 1. Administer oxygen via a nonrebreather mask 2. Initiate IV therapy with a large-bore catheter 3. Insert an NG tube 4. Administer Famotidine Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer famotidine when the client is no longer bleeding.

Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation. Anticipated or Contraindicated - Obtain vital signs every hour. - Administer an intermittent IV bolus of fluid within 1 hour. - Obtain blood cultures. - Insert a nasogastric tube.

Anticipated: - Obtain vital signs every hour. - Obtain blood cultures. - Insert a nasogastric tube. Contraindicated: - Administer an intermittent IV bolus of fluid within 1 hour. Rationale: - When generating solutions when planning the client's care, the nurse should anticipate that the provider prescriptions for obtaining blood cultures, obtaining vital signs ever hour and insert a nasogastric tube are prescriptions that could be indicated to manage the client's current condition. The anticipated provider prescription for administering a bolus of IV fluid is contraindicated for the client because the client's vital signs are within the expected reference range and the client is not experiencing findings that indicate a decrease in their fluid volume.

Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache." Client is alert and oriented to person, place, and time. Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs. Pedal pulses +2 bilaterally. Client reports decreased appetite for the past 2 days. Temperature 38.6° C (101.5° F) Oxygen saturation 88% on room air Anticipated or Nonessential or Contraindicated A. Administer oxygen at 3 L/min via nasal cannula. B. Famotidine 40 mg PO daily C. Limit the client's fluid intake to 1,500 mL per day. D. Obtain a sputum culture and sensitivity. E. Cough and deep breathe every 2 hr. F. Acetaminophen 500 mg PO every 6 hr as needed. G. Perform neurological checks every 2 hr.

Anticipated: A - The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. D - The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. E - The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. F - The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Nonessential: B - Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily. G - The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Contraindicated: C - The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated.

Cough: - Client states that sleep during the night is interrupted by coughing and shortness of breath most nights of the week. Temp: 38.7° C (101.6° F) Breath Sounds: Wheezes noted bilaterally. Use of accessory muscles noted. Client speaks in short phrases, with report of increased shortness of breath when speaking. Client states that sleep during the night is interrupted by coughing and shortness of breath most nights of the week. ABG: - pH 7.30 (7.35 to 7.45) - PaO2 70 mm Hg (80 to 100 mm Hg) - PaCO2 47 mm Hg (35 to 45 mm Hg) - HCO3- 24 mEq/L (21 to 28 mEq/L) - SaO2 90% on room air (95% to 100%) RR: 24/min HR: 104/min For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Cough (3) - Emphysema, Asthma, Pneumonia Temperature (1) - Pneumonia - Fever is a manifestation of pneumonia and is related to inflammation or infection. Breath Sounds (3) - Emphysema, Asthma, Pneumonia - It is the result of narrowed airways and alveoli. ABG (2) - Results indicate Respiratory Acidosis (manifestation) of Emphysema and Pneumonia RR (3) - Emphysema, Asthma, Pneumonia HR (3) - Client is experiencing Tachycardia which is a manifestation of Emphysema, Asthma, Pneumonia

Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small amount of blood in the stool, and a 12% weight loss over the past 2 months. Client's weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn's disease and a seizure disorder that is managed with diet and medication. Respirations are equal and unlabored. S1S​2 heart tones auscultated. Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation. Appendicitis or Crohn's Disease - Stool Color - Pain location - GI concerns - Temperature

When analyzing cues, the nurse should identify that the client's assessment findings of right lower quadrant pain, fever, and client report of anorexia indicates appendicitis. When analyzing cues, the nurse should identify that the client's assessment findings of blood in stool, right lower quadrant pain, fever, and client report of anorexia indicates Crohn's disease.