RNSG 1324 Practice Final Exam Questions Pass Point Spring 2018

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: A. advise the client to avoid iron-rich foods. B. report the finding to the health care provider (HCP). C. encourage the client to increase fluid intake. D. place the client on contact precautions.

B. report the finding to the health care provider (HCP) Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black; the odor of the stool is very offensive. The nurse should instruct the client to report the incidence of black stools promptly to the HCP. Increasing fluids or avoiding iron-rich foods will not change the stool color or consistency if the stools contain digested blood. Until other information is available, it is not necessary to initiate contact precautions.

The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? A. Serum sodium level of 135 mEq/L B. Temperature of 99.2° F (37.3° C) C. Serum potassium level of 4.9 mEq/L D. Urine output of 20 ml/hour

D. Urine output of 20 ml/hour Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings.

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? A. Respirations B. Blood pressure C. Cardiac rhythm D. Temperature

C. Cardiac rhythm The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life- threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.

When taking a telephone order from a physician, the nurse verifies that he or she understands the order by: A. Asking the physician to summarize the orders given. B. Repeating the order back to the physician. C. Confirming the order with the nurse manager. D. Faxing the written order to the physician's office.

B. Repeating the order back to the physician. The nurse should repeat every telephone order back to the physician to ensure that he or she correctly understands what was ordered. If the nurse is unsure of the order given by phone, he or she asks the physician to repeat it, but this is not a summary of the order. Confirming the order with the nurse manager is not an effective means to verify the order because the nurse manager will likely not be available during the telephone conversation.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure? A. Provide a diet high in protein and restrict fluids as ordered. B. Prepare for temporary peritoneal dialysis or hemodialysis. C. Monitor for hypotension and maintain accurate intake and output records. D. Restrict sodium and potassium and restrict fluids as ordered.

D. Restrict sodium and potassium and restrict fluids as ordered. In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

Which laboratory finding is present in nephrotic syndrome? A. hypercalcemia B. decreased total serum protein C. decreased hematocrit D. hyperglycemia

B. decreased total serum protein A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a finding related to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome

The nurse is caring for an infant diagnosed with thrush. Which instruction would the nurse give to a client's mother who will be administering nystatin oral solution? A. Administer half the dose before and half after a feeding. B. Mix the drug with small amounts of formula in bottle. C. Administer the drug right after meals by swabbing the mouth. D. Administer the drug right before meals by using a gauze pad.

C. Administer the drug right after meals by swabbing the mouth. Nystatin oral solution is an antifungal medication used to treat fungal or yeast infections. Nystatin oral solution should be swished around the mouth after eating for the best contact with mucous membranes. Taking the drug before or with meals does not allow for optimal contact with mucous membranes.

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

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

The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: A. hypokalemia. B. hypernatremia. C. hyperkalemia. D. hypercalcemia.

C. hyperkalemia. Hyperkalemia is a common complication of acute renal failure. It's life- threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and: A. folic acid. B. iron. C. vitamin D. D. potassium.

C. vitamin D. Typically, clients with hypoparathyroidism are ordered daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn't cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn't require daily supplements of these substances to maintain a normal serum calcium level.

Which information should be included in the teaching plan for a client with osteoporosis? Select all that apply. A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. B. Use alcohol in moderation because a moderate intake has no known negative effects. C. Avoid of high-fat foods, such as avocados, salad dressings, and fried foods. D. Try swimming as a good exercise to maintain bone mass. E. Choose good calcium sources, such as figs, broccoli, and almonds.

A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. B. Use alcohol in moderation because a moderate intake has no known negative effects. E. Choose good calcium sources, such as figs, broccoli, and almonds. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density, but excessive alcohol intake does reduce bone density. Swimming, biking, and other non-weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid high-fat foods.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison's crisis following surgery? A. methylprednisolone sodium succinate intravenously B. fludrocortisone subcutaneously C. prednisone orally D. spironolactone intramuscularly

A. methylprednisolone sodium succinate intravenously A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Spironolactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating: A. "It looks like you aren't following the ordered diabetic diet." B. "It tells us about your sugar control for the last 3 months." C. "Your insulin regimen must be altered significantly." D. "The test must be repeated following a 12-hour fast."

B. "It tells us about your sugar control for the last 3 months." The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

A client undergoes extracorporeal shock wave lithotripsy (ESWL) to break up and remove renal calculi. Which nursing measure is appropriate for the postoperative care of this client? A. Maintain the client on strict bed rest for 48 hours after the procedure. B. Instruct the client to anticipate hematuria for about 24 hours after the procedure. C. Limit fluid intake to 1,000 mL/day until all stone fragments have been passed. D. Instruct the client to anticipate a decrease in urine output.

B. Instruct the client to anticipate hematuria for about 24 hours after the procedure. It is normal for hematuria to occur for up to 24 hours after ESWL. Hematuria that occurs for longer than 24 hours should be reported to the health care provider. ESWL is usually performed on an outpatient basis. Strict bed rest is not necessary after the procedure. Urine output should not decrease. Any difficulty urinating should be reported. Fluid intake should be increased to 2 to 3 L/day, not decreased.

A client who is receiving a blood transfusion begins to have difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which complication? A. acute hemolytic reaction B. circulatory overload C. anaphylactic reaction D. sepsis

B. circulatory overload The symptoms of difficulty breathing, elevated blood pressure, and cough are indicative of circulatory overload. Circulatory overload occurs when blood is infused more rapidly than the circulatory system can accommodate. Anaphylactic reactions are manifested by urticaria, wheezing, and shock. Sepsis begins with a rapid onset of chills and fever. Acute hemolytic reaction is typically manifested by chills, fever, low back pain, and flushing.

A client with chronic renal failure is undergoing hemodialysis. Postdialysis, the client weighs 59 kg. The nurse should teach the client to: A. control the amount of protein intake to 59 to 70 g/day. B. increase sodium in the diet to 4 g/day. C. limit total calories consumed each day to 1,000. D. increase fluid intake to 3,000 mL each day.

A. control the amount of protein intake to 59 to 70 g/day. Hemodialysis clients have their protein requirements individually tailored according to their postdialysis weight. The protein requirement is 1.0 to 1.2 g/kg body weight per day. Hence, for a 59-kg weight, the amount of protein will be 59 to 70 g/day. Sodium should be restricted to 3 g/day. The client should obtain sufficient calories; if calories are not supplied in adequate amount, the body will use tissue protein for energy, which will lead to a negative nitrogen balance and malnutrition. Fluid intake needs to be restricted. The fluid amount is restricted to 500 to 700 mL plus the urine output.

The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome? A. decreased abdominal girth B. increased respiratory rate C. decreased heart rate D. increased caloric intake

A. decreased abdominal girth Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.

On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? A. A 55-year-old complaining of chest pressure B. A 60-year-old client experiencing nausea and vomiting C. A 20-year-old client with a blood glucose level of 70 mg/dl D. An 80-year-old client with a blood glucose level of 350 mg/dl

A. A 55-year-old complaining of chest pressure The nurse should assess the client with chest pressure first because he might be experiencing a myocardial infarction. The blood glucose levels in 20-year-old client and 80-year-old client are abnormal, but not life threatening; therefore, these clients don't require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.

A client diagnosed with hypothyroidism (myxedema) is receiving levothyroxine. Which assessment findings would require a nursing intervention? Select all that apply. A. Mild chest pain B. Heart rate of 132 beats/min C. Adventitious breath sounds D. Dysrhythmias E. Dysuria

A. Mild chest pain B. Heart rate of 132 beats/min D. Dysrhythmias Levothyroxine (thyroid hormone replacement medication) increases cardiac demand, which can cause increased heart rate, palpitations, and chest pain. These clients are at risk for a myocardial infarction. Adventitious breath sounds are abnormal, extra sounds, but are not related to receiving levothyroxine. Dysuria means painful urination and is not a side effect of levothyroxine.

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. "He knows who we are, but that is about it. We do not know what to say to him." What should the nurse tell the family? Select all that apply. A. "Correct him when he is hearing and seeing things that are not there." B. "Raise your voice a bit so you are sure he hears you." C. "Include him in your conversation, instead of talking about him while he is present." D. "Answer his questions simply, honestly, slowly, and clearly." E. "Occasionally remind him of the time, day, and place when he does not remember."

C. "Include him in your conversation, instead of talking about him while he is present." D. "Answer his questions simply, honestly, slowly, and clearly." E. "Occasionally remind him of the time, day, and place when he does not remember." Clear communication is crucial for a client with delirium. The family must include the client in all conversations and keep him oriented to time and place. It is inappropriate to argue with a client's hallucinations because they are real to the client. Speaking more loudly will not help this client hear more distinctly and may increase the client's confusion.

Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube? A. Abdominal X-rays B. Injection of a small amount of air while listening with a stethoscope over the abdominal area C. A check of the pH of fluid aspirated from the tube D. Visualization of the measurement mark on the tube made at the time of insertion

C. A check of the pH of fluid aspirated from the tube Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? A. Metabolic acidosis and hyperkalemia B. Metabolic alkalosis and hypokalemia C. Metabolic acidosis and hypokalemia D. Metabolic alkalosis and hyperkalemia

C. Metabolic alkalosis and hypokalemia Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.

A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage: A. ineffective airway clearance. B. risk for injury. C. drug and alcohol abuse. D. severe pain.

D. severe pain Acute pancreatitis is very painful; management involves interventions for pain. Although alcohol abuse is often implicated in pancreatitis, drug and alcohol counseling will be an individual consideration. Risk for injury and ineffective airway clearance are not typically associated with acute pancreatitis.

Which infections require contact precautions? Select all that apply: A. Tuberculosis B. Clostridium difficile C. Measles D. Pertussis E. Methicillin-resistant staphylococcus aureus

B. Clostridium difficile E. Methicillin-resistant staphylococcus aureus C. difficile and methicillin-resistant S. aureus are easily transmitted through direct contact or contact with items in the client's environment. To prevent the spread of infection, clients should be cared for using contact precautions in addition to standard precautions. Tuberculosis and measles require airborne precautions. Pertussis requires droplet precautions.

A nurse asks a client to sign the consent for surgery. Which of the following is an appropriate situation for giving valid consent? A. The client has cognitive capacity to make decisions. B. The client tells the nurse that the physician is capable and signs without reading the information on the consent. C. The client still has further questions about the surgery, but the nurse encourages the consent to be signed and will attach a note to the chart for the physician. D. The client has his/her spouse sign because the client is in too much pain from the condition.

A. The client has cognitive capacity to make decisions. Cognitive capacity is one of the supported reasons for consent to occur. All the other choices need further clarification and information gathering from the nurse, as well as communication to the client or the physician.

Following surgery, to evaluate the effectiveness of the client's use of an incentive spirometer, the nurse should determine if the client: A. can breathe more easily. B. has stronger abdominal muscles. C. has increased circulation in the extremities. D. is ready to ambulate without pain.

A. can breathe more easily. Incentive spirometry promotes lung expansion and increases respiratory function. When used properly, an incentive spirometer causes sustained maximal inspiration and increased cardiac output.

The nurse is obtaining vital signs from a client who is receiving an intravenous antibiotic for the first time. Which observation made by the nurse requires immediate intervention? Select all that apply. A. reports mouth is dry B. inspiratory wheezes C. heart rate of 86 D. reports severe itching all over E. rash on skin of face, chest, and arms

B. inspiratory wheezes D. reports severe itching all over E. rash on skin of face, chest, and arms Rash, inspiratory wheezes, and reports of severe itching indicate that the client is having an allergic reaction to the antibiotic. A heart rate of 86 is within normal limits and reports of mouth being dry is not indicative of an allergic reaction.

During an initial shift assessment, a nurse finds a diabetic client who is lethargic and who has rapid, deep respirations. Which of the following actions should the nurse take? A. Start oxygen at 2 L/min as needed B. Contact the healthcare provider C Administer a saline bolus as needed D. Administer IV glucagon bolus as needed

C Administer a saline bolus as needed The rapid, deep (Kussmaul) respirations are compensatory and indicate metabolic acidosis. There is an immediate need for correction of the acidosis with a saline bolus to prevent hypovolemia. This will be followed by assessment of glucose level and insulin administration to allow the glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of glucagon will further increase the blood sugar levels.

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? A. "I'll increase my intake of protein during exacerbations." B. "I'll snack on nuts, olives, and popcorn during flare-ups." C. "I should increase my intake of fresh fruits and vegetables during remissions." D. "I'll incorporate foods rich in omega-3 fatty acids into my diet."

C. "I should increase my intake of fresh fruits and vegetables during remissions." A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.

When administering atropine sulfate preoperatively to a client scheduled for lung surgery, the nurse should tell the client? A. "This medicine will reduce the risk of postoperative infection." B. "This medicine will make you drowsy." C. "This medicine will make your mouth feel dry." D. "This medicine will help you relax."

C. "This medicine will make your mouth feel dry." Atropine is an anticholinergic drug that decreases mucus secretions in the respiratory tract and dries the mucus membranes of the mouth, nose, pharynx, and bronchi. Atropine does not cause drowsiness or relaxation. Moderate to large doses cause tachycardia and palpitations. Large doses cause excitement and manic behavior. Atropine does not reduce the risk of postoperative infection.

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first? A. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes. B. Draw blood for an arterial blood gas. C. Administer bronchodilators as prescribed. D. Encourage the client to relax and breathe slowly through the mouth.

C. Administer bronchodilators as prescribed. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? A. Strain urine at home regularly. B. Follow measures to alkalinize the urine. C. Increase daily fluid intake to at least 2 to 3 L. D. Eliminate dairy products from the diet.

C. Increase daily fluid intake to at least 2 to 3 L. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

What instructions should the nurse give to the parents of an 8-year-old child with asthma who is being switched from parenteral steroid therapy to a daily dose of oral prednisone? A. "Administer the dose before bedtime to minimize adverse effects." B. "Make sure to give the pill intact to maintain the enteric coating." C. "Give the medication according to the child's response." D. "Have the child take the dose with meals to prevent gastric irritation."

D. "Have the child take the dose with meals to prevent gastric irritation." Prednisone causes severe gastric upset. Therefore, it should be given with food. It is recommended that the daily dose be given in the morning before 0900. Given at this time, the medication will suppress adrenal cortex activity less, which may reduce the risk of hypothalamic-pituitary-adrenal axis suppression. The drug must be given as prescribed and not titrated to response. If the drug has been given over a long period, abrupt cessation can cause serious side effects. Because the pills are not enteric coated, they may be crushed and mixed with food if the child has difficulty swallowing them.

The client is to undergo a series of diagnostic tests to determine if the client's cognitive impairment is treatable. Which state can lead to nonreversible cognitive impairment? A. cerebral abscess B. delirium C. electrolyte imbalance D. Alzheimer's disease

D. Alzheimer's disease Alzheimer's disease is a progressive chronic disease. While medications can slow the progression, its course cannot be reversed. Cerebral abscess, delirium, and electrolyte imbalance are treatable causes of cognitive impairment.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? A. Fear B. Urinary retention C. Toileting self-care deficit D. Excess fluid volume

D. Excess fluid volume A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance.

A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible? A. To decrease the possibility of nausea and vomiting B. To decrease the amount of glycogen in her system C. To stimulate her appetite D. To restore liver glycogen and prevent secondary hypoglycemia

D. To restore liver glycogen and prevent secondary hypoglycemia A client with type 1 diabetes who requires glucagon should be given a complex carbohydrate snack as soon as possible to restore the liver glycogen and prevent secondary hypoglycemia. A complex carbohydrate snack doesn't decrease the possibility of nausea and vomiting or stimulate the appetite, and it increases the amount of glycogen in the system.

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to the use of PPE? A. "PPE should be used when you risk exposure to blood or bodily fluids." B. "You should be aware that PPE is used when caring for any client in the hospital." C. "In the future, have the physician write an order for PPE for clients with colostomies." D. "If you're not using PPE, you need to be careful not to touch any of the drainage."

A. "PPE should be used when you risk exposure to blood or bodily fluids." Personal protective equipment or a barrier should be used when there is a risk that blood or other bodily fluids may come in contact with the nurse's skin or mucous membranes. This is a decision that can be independently made by the nurse and can be used when the nurse deems it appropriate. It is not necessary to use personal protective equipment or a barrier in every client contact. It is a nursing decision and does not need a physician's order.

A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client? A. "See your health care provider (HCP) for an early diagnosis and treatment of a sore throat." B. "As long as you do not have a fever, it is sufficient to gargle daily with an antibacterial mouthwash." C. "Unscented bar soap may be used in showers." D. "You may continue to utilize the previously prescribed antibiotics until they are gone."

A. "See your health care provider (HCP) for an early diagnosis and treatment of a sore throat." Acute poststreptococcal glomerulonephritis usually follows a streptococcal throat or skin infection by 1 to 2 weeks. Streptococcus-type infections require medical intervention with antibiotics. Antibacterial mouthwashes do not kill streptococci. Previously prescribed antibiotics may not be effective against streptococci, and may also be expired. Bar soap fragrance has no impact on its ability to kill bacteria that reside on ski

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication? A. "Swallow this medication whole. Do not chew it." B. "Take this medication before going to bed." C. "Dissolve the medication in a full glass of water." D. "Store this medication in the refrigerator."

A. "Swallow this medication whole. Do not chew it." Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.

A client has polycystic kidney disease. The client asks the nurse, "How did I get these fluid-filled bubbles on my kidneys?" How should the nurse respond to help the client understand risk factors for this disease process? A. "There is a higher incidence of polycystic kidney disease among blood relatives." B, "Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney disease." C. "Second-hand smoke puts you at greater risk for developing cysts." D. "Drinking alcohol daily allows the kidneys to develop cysts."

A. "There is a higher incidence of polycystic kidney disease among blood relatives." Although it is not clearly understood why cysts form in polycystic kidney disease, the condition is known to be inherited. Environmental exposures such as smoking and breathing second-hand smoke promote development of bladder cancer. Although drinking alcohol requires the kidneys to excrete the alcohol, it is not thought to cause the kidneys to develop cysts. Exposure to dyes used in foods does not increase the risk for polycystic disease.

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A. Apply antiembolic stockings. B. Initiate oxygen therapy as needed. C. Obtain vital signs. D. Assess the client's breath sounds. E. Keep the client oriented.

A. Apply antiembolic stockings. C. Obtain vital signs. E. Keep the client oriented. It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the UAP. The UAP can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with the health care provider's prescriptions. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply. A. Assist the client with activities of daily living (ADLs) as necessary. B. Engage the client in complex discussions to help improve memory. C. Make frequent changes in the client's routine. D. Furnish the client's environment with familiar possessions. E. Assign tasks in simple steps.

A. Assist the client with activities of daily living (ADLs) as necessary. D. Furnish the client's environment with familiar possessions. E. Assign tasks in simple steps. A client with Alzheimer's disease experiences progressive deterioration in cognitive functioning. Familiar possessions may help to orient the client. The client should be encouraged to perform ADLs as much as possible but may need assistance with certain activities. Using a step-by-step approach helps the client complete tasks independently. A client with Alzheimer's disease functions best with consistent routines. Complex discussions do not improve the memory of a client with Alzheimer's disease.

A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which signs and symptoms? Select all that apply. A. Cardiac arrhythmias B. Constipation C. Fractures D. Trousseau's sign E. Decreased clotting time F. Drowsiness and lethargy

A. Cardiac arrhythmias C. Fractures D. Trousseau's sign Chronic renal failure is the slow process of losing kidney function over time. At some point, the kidney will not be able to remove excess fluid and wastes from the body causing fluid and electrolyte complications. Hypocalcemia is a calcium deficit that causes nerve fiber irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures. Drowsiness and lethargy are not typically associated with hypercalcemia.

A client is newly diagnosed with Alzheimer's disease. When planning this client's care, the nurse should include which aspects of care? Select all that apply. A. Instruct the family regarding the disease progression. B. Assess the client's nutritional status. C. Provide a safe environment. D. Help the client organize his room. E. Schedule physical therapy sessions twice a day.

A. Instruct the family regarding the disease progression. B. Assess the client's nutritional status. C. Provide a safe environment. D. Help the client organize his room. Preventing injury is an important goal of care for a client with Alzheimer's disease and can be achieved by providing a safe, structured environment, helping him organize his surroundings, and assessing nutritional level, given that many Alzheimer clients are malnourished. Other care goals include establishing effective communication to help the client and his family adjust to the client's altered cognitive abilities, offering emotional support, teaching the client and his family about the disease, and encouraging the client to exercise to help maintain mobility. Alzheimer's disease cannot be reversed. Cognitive losses cannot be prevented because Alzheimer's disease is an insidious, degenerative dementia that eventually causes disorientation; severe deterioration of memory, language, and motor ability; emotional lability; and physical and intellectual disability.

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication? A. Myxedema coma B. Thyroid storm C. Myocardial infarction D. Congestive heart failure

A. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Although thyroid storm is life-threatening, it's caused by severe hyperthyroidism. Myocardial infarction and congestive heart failure may eventually occur in the client with hypothyroidism who is untreated or undertreated for long periods of time.

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply. A. Numbness B. Aphasia C. Polyuria D. Tingling E. Polydipsia F. Muscle twitching and spasms

A. Numbness D. Tingling F. Muscle twitching and spasms When the parathyroid gland is removed, the body may not produce enough parathyroid hormone to regulate calcium and phosphorous levels. The symptoms of hypocalcemia include peripheral numbness, tingling, and muscle spasms. Aphasia is not a symptom of calcium depletion. Polyuria and polydipsia are symptoms of diabetes mellitus.

The nurse is caring for a client who is in status asthmaticus. What is the nurse's priority action? A. Place the client on oxygen. B. Call the healthcare provider. C. Administer magnesium sulfate intravenously. D. Administer albuterol.

A. Place the client on oxygen. The nurse should apply oxygen first for a client in status asthmaticus, and medications would follow. A short-acting beta-agonist such as albuterol may be initially administered. Magnesium sulfate may be prescribed to relax smooth muscles. The nurse would notify the healthcare provider as the condition progresses.

A client is being discharged to home 3 days after transurethral resection of the prostate (TURP). What should the nurse instruct the client to do? Select all that apply. A. Report a temperature over 99° F (37.2° C). B. Increase calorie intake by eating six small meals a day. C. Take deep breaths and cough every 2 hours. D. Drink at least 3,000 mL of water per day. E. Report bright red bleeding to the health care provider (HCP).

A. Report a temperature over 99° F (37.2° C). D. Drink at least 3,000 mL of water per day. E. Report bright red bleeding to the health care provider (HCP). The nurse should instruct the client to drink a large amount of fluids (about 3,000 mL/day) to keep the urine clear. The urine should be almost without color. About 2 weeks after TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the surgeon or go to the emergency department if at any time the urine turns bright red. The nurse should also instruct the client to report signs of infection such as a temperature over 99° F (37.2° C). The client is not specifically at risk for nutritional problems after TURP and can resume a diet as tolerated. The client is not specifically at risk for airway problems because the procedure is done under spinal anesthesia and the client does not need to take deep breaths and cough.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? A. Urine output of 250 ml/24 hours B. Temperature of 100.2° F (37.8° C) C. Serum creatinine level of 1.2 mg/dl (0.1 mmol/L) D. Blood urea nitrogen (BUN) level of 22 mg/dl (1.2 mmol/L)

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

Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? A. calcium gluconate B. sodium bicarbonate C. echothiophate iodide D. sodium phosphate

A. calcium gluconate The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid.

A 34-year-old female is diagnosed with hypothyroidism. What should the nurse assess the client for? Select all that apply. A. constipation B. rapid pulse C. menorrhagia D. fine, thin hair with hair loss E. weight gain of 10 lb (4.5 kg) F. decreased energy and fatigue

A. constipation C. menorrhagia E. weight gain of 10 lb (4.5 kg) F. decreased energy and fatigue Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism.

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should be reported to the surgeon and anesthesiologist? A. creatinine, 2.6 mg/dL (230 µmol/L) B. hemoglobin, 12.2 g/dL (122 g/L) C. red blood cells, 4.5 million/mm3 (4.5 X 1012/L) D. blood urea nitrogen, 15 mg/dL (5.4 mmol/L)

A. creatinine, 2.6 mg/dL (230 µmol/L) The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL (230 µmol/L), which is higher than the normal range of 0.1 to 0.4 mg/dL (9 to 35 µmol/L). An elevated serum creatinine value indicates that the kidneys are not filtering effectively and has important implications for the surgical client because many anesthesia and analgesia medications need to be filtered out through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level are within normal limits and do not need to be reported to the surgeon.

A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse should verify that the client has: A. discontinued use of blood thinners. B. followed a low-residue diet. C. performed abdominal tightening exercises. D. signed a last will and testament.

A. discontinued use of blood thinners. Nurses should verify that clients having surgery discontinued use of any blood thinners to prevent postoperative bleeding. Prior to bowel resection the client should follow a high-residue diet with increased fluids. Abdominal tightening exercises are not necessary before this surgery. Clients may write a will before surgery, but the nurse does not have to inquire about it.

A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The expected outcome of using this drug is that it helps: A. reduce the vascularity of the thyroid gland. B. slow progression of exophthalmos. C. decrease the body's ability to store thyroxine. D. increase the body's ability to excrete thyroxine.

A. reduce the vascularity of the thyroid gland. Thyrotoxicosis means an excess of thyroid hormone in the body. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine.

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement? A. "The head of your bed must remain flat for 24 hours after surgery." B. "You must avoid hyperextending your neck after surgery." C. "You won't be able to swallow for the first day or two." D. "You should avoid deep breathing and coughing after surgery."

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

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs? A. Monitor the client's theophylline level before administering the medications. B. Administer the salmeterol and then administer the triamcinolone. C. Allow the client to choose the order in which the drugs are administered. D. Administer the triamcinolone and then administer the salmeterol.

B. Administer the salmeterol and then administer the triamcinolone. A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

A nurse is teaching a client about taking antihistamines. Which information should the nurse include in the teaching plan? Select all that apply. A. The effect of antihistamines is not felt until a day later. B. Operating machinery and driving may be dangerous while taking antihistamines. C. Increase fluid intake to 2,000 mL/day. D. Continue taking antihistamines even if nasal infection develops. E. Do not use alcohol with antihistamines.

B. Operating machinery and driving may be dangerous while taking antihistamines. C. Increase fluid intake to 2,000 mL/day. E. Do not use alcohol with antihistamines. Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least 2,000 ml (about eight glasses) per day due to the drying effect of the drug. Antihistamines have no antibacterial action, and are not used to treat nasal infections.. The effect of antihistamines is prompt, not delayed.

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply. A. Explain to the client that a tube will be inserted through the nose and into the stomach. B. Report hemoptysis, stridor, or dyspnea immediately. C. Keep suction equipment available. D. Instruct that the client will be awake during the procedure. E. Assess cough and gag reflexes after the procedure. F. Feed the client immediately after the procedure.

B. Report hemoptysis, stridor, or dyspnea immediately. C. Keep suction equipment available. E. Assess cough and gag reflexes after the procedure. Suctioning equipment should be kept available to clear the airway and prevent aspiration. Preoperative sedation and local anesthesia depress the gag and cough reflexes, so the nurse must assess for the return of these reflexes after bronchoscopy. Hemoptysis, stridor, or dyspnea should be reported immediately, because these findings indicate respiratory distress possibly caused by a pneumothorax, a complication of bronchoscopy. The client should not eat immediately after the procedure. Food and fluid are withheld until the gag reflex returns. The client is sedated for the procedure. A bronchoscopy involves inserting a fiberoptic endoscope into the bronchi, not the stomach.

Which concept refers to a professional nurse's role in client advocacy? A. The nurse makes decisions for clients who can't make decisions for themselves. B. The nurse promotes and protects the client's interests and rights. C. The nurse follows the basic standards of care and hospital policies and procedures for providing client care. D. The nurse adopts a paternalistic approach to client care.

B. The nurse promotes and protects the client's interests and rights. The nurse who understands the advocacy role promotes, protects and, thereby, advocates a client's interests and rights in an effort to make the client well. The nurse recognizes that her first duty is to protect and care for the client's health and safety. True advocacy encourages and helps clients reach decisions that express their own beliefs and values. The nurse doesn't make decisions for clients but provides care for the acutely ill client with the consent of his significant other. If the client has no significant other, a health care power of attorney or the client's living will dictates what care the nurse should provide. Standards of care are the basis for providing safe, competent nursing care and set minimum criteria for proficiency on the job, enabling the nurse and others to judge the quality of care provided. Paternalism violates self-determination and advocacy by acting for another. A nurse acting as a client advocate helps clients exercise their freedom of self-determination.

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client? A. Percuss the cannula for bruits each shift. B. Use the unaffected arm for blood pressure measurements. C. Draw blood from the cannula for routine laboratory work. D. Inject heparin into the cannula each shift.

B. Use the unaffected arm for blood pressure measurements. The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, IV therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.

A healthcare provider gives the nurse an order over the telephone. Which of the following is the appropriate nursing action? A. No action is needed at this time. B. Verify the order by repeating it back to the healthcare provider. C. Request that a second healthcare provider repeat the order to the nurse over the telephone. D. Explain that the healthcare provider must sign the order within 1 hour.

B. Verify the order by repeating it back to the healthcare provider. When taking a medication order over the telephone, standard practice requires verbal verification of the order and the physician's written signature within 24 hours. The nurse practice act does not prohibit taking medication orders over the telephone. Having a second physician repeat the order opens another avenue for misinterpretation and error. Insisting that the physician sign the order within 1 hour is unrealistic.

A client is being discharged after undergoing a thyroidectomy. Which discharge instructions are appropriate for this client? Select all that apply. A. Report signs and symptoms of hypoglycemia. B. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician. C. Carry injectable dexamethasone at all times. D. Take thyroid replacement medication as ordered. E. Avoid all OTC medications.

B. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician. D. Take thyroid replacement medication as ordered. A thyroidectomy is the surgical removal of all or part of the thyroid. After removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy, restlessness, cold sensitivity, and dry skin, which may indicate the need for a higher dosage of medication. The thyroid gland does not regulate blood glucose level; therefore, signs and symptoms of hypoglycemia are not relevant for this client. Injectable dexamethasone is not needed for this client, it is used to treat inflammation. Some OTC medications (such as non-aspirin products) are allowable.

The most significant sign of acute renal failure is: A. elevated body temperature. B. decreased urine output. C. increased blood pressure. D. increased urine specific gravity.

B. decreased urine output. A sudden change in urine output is typical of acute renal failure. Most commonly, the initial change is greatly decreased urine output. Later in the course of acute renal failure, the client may have marked diuresis (nonoliguric failure). A high body temperature or sudden increase in blood pressure is not typically associated with acute renal failure. Urine specific gravity usually is within a low-normal range because the kidneys have difficulty concentrating urine.

A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client's care to: A. assess whether the client is a good candidate for surgery. B. help the client cope with the anxiety associated with changes in body image. C. evaluate the client's need for mental health intervention. D. assess suicidal risk postoperatively.

B. help the client cope with the anxiety associated with changes in body image. Many clients who undergo surgery for creation of an ileal conduit experience anxiety associated with changes in body image. The mental health practitioner can help the client cope with these feelings of anxiety. Mental health practitioners don't evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time.

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to: A. have a serum potassium level drawn weekly. B. weigh daily. C. keep a daily record of urine output. D. take blood pressure daily.

B. weigh daily. Monitoring daily weight will help determine the effectiveness of diuretic therapy. A client who gains weight without diet changes most probably is retaining fluids, so the diuretic therapy should be adjusted. Blood pressure monitoring is useful when diuretics are prescribed to control blood pressure. However, in clients with heart failure, the primary indication is to promote sodium and water excretion by the kidneys. While it may be useful to monitor intake and urinary output in the hospital, daily weights are a sensitive indicator of fluid status and more practical for home management. The client may be told to eat a potassium-rich diet; however, serum potassium levels are not used to determine the effectiveness of diuretic therapy.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? A. Have the client talk with a member of the clergy about these concerns. B. Notify the surgeon of the client's question. C. Arrange for a person with an ostomy to visit the client preoperatively. D. Tell the client to worry about those concerns after surgery.

C. Arrange for a person with an ostomy to visit the client preoperatively. If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the health care provider (HCP) should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.

A client, hospitalized with heart failure, is receiving digoxin and furosemide intravenously and now has continuous ringing in the ears. What is the appropriate action for the nurse to take at this time? A. Ask the client about taking aspirin in addition to other medications. B. Note the observation in the medical record and plan to reassess in 2 hours. C. Discontinue the furosemide and notify the health care provider (HCP). D. Obtain a digoxin level to check for toxicity.

C. Discontinue the furosemide and notify the health care provider (HCP). The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the furosemide. The appropriate action is for the nurse to stop the furosemide and notify the HCP. If the drug is stopped soon enough, permanent hearing loss can be avoided, and the tinnitus should subside. The nurse should note the observation in the medical record but should not delay action. Tinnitus is not a symptom of digoxin toxicity. Aspirin can cause tinnitus, but the nurse should first investigate the obvious cause of tinnitus, which in this case is the furosemide.

Which medication is considered safe during pregnancy? A. Magnesium hydroxide B. Aspirin C. Insulin D. Oral antidiabetic agents

C. Insulin Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.

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

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

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which of the following is the most important effect to report to the physician? A. Insomnia and loss of weight B. Increased temperature and metabolic rate C. Palpitations and chest pain on exertion D. Increased energy level and reduction of edema

C. Palpitations and chest pain on exertion Assessment of the effects of severe hypothyroidism on the circulatory system is important. Serum cholesterol levels are also elevated in clients with hypothyroidism. As the metabolic rate increases with the thyroid replacement therapy, there is more demand on the heart, and angina and palpitations may occur. All of the choices are expected effects once the replacement hormone is started. There is an increase in temperature, a loss in weight, and increased energy levels.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A. Bicarbonate (HCO3-) B. Partial pressure of arterial carbon dioxide (PaCO2) C. Partial pressure of arterial oxygen (PaO2) D. pH

C. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

A toddler is admitted to the facility with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to see? A. Ketonuria B. Polyuria C. Proteinuria D. Glycosuria

C. Proteinuria In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins, resulting in massive proteinuria. Nephrotic syndrome typically doesn't cause glycosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it's more likely to decrease urine output than to cause polyuria (excessive urine output).

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

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

A 48-year-old female client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply. A. Plan for a thyroidectomy B. High-protein, high-calorie diet C. Use of stool softeners D. Thyroid hormone replacements E. Review of the procedure for thyroid radiation therapy F. High-fiber, low-calorie diet

C. Use of stool softeners D. Thyroid hormone replacements F. High-fiber, low-calorie diet The treatment for hypothyroidism includes a high-fiber, low-calorie diet, because weight gain and constipation are two symptoms of the disorder. Stool softeners are prescribed to prevent constipation, and thyroid hormone replacements are needed to supplement the under-functioning thyroid gland. A high-protein, high-calorie diet is commonly used for clients with hyperthyroidism, along with a thyroidectomy or irradiation of the thyroid gland.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? A. increased fremitus B. Cheyne-Stokes respirations C. diminished or absent breath sounds on the affected side D. decreased sensation on the affected side

C. diminished or absent breath sounds on the affected side Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration.

The client with acute pyelonephritis wants to know the possibility of developing chronic pyelonephritis. The nurse's response is based on knowledge of which disorder that most commonly leads to chronic pyelonephritis? A. acute pyelonephritis B. acute renal failure C. recurrent urinary tract infections D. glomerulonephritis

C. recurrent urinary tract infections Chronic pyelonephritis is most commonly the result of recurrent urinary tract infections. Chronic pyelonephritis can lead to chronic renal failure. Single cases of acute pyelonephritis rarely cause chronic pyelonephritis. Acute renal failure is not a cause of chronic pyelonephritis. Glomerulonephritis is an immunologic disorder, not an infectious disorder.

After a client has had a bronchoscopy under local anesthesia, the nurse should: A. irrigate the nasogastric (NG) tube with 30 ml of normal saline every 2 hours. B. offer 200 ml of oral fluids every hour to liquefy lung secretions. C. restrict oral intake until the gag reflex returns. D. observe the abdomen for signs of distention and board-like rigidity.

C. restrict oral intake until the gag reflex returns. Preoperative sedation and local anesthesia impair swallowing and the laryngeal reflex, which is protective in nature. The nurse will restrict oral intake until the gag and swallow reflexes return. The client should be positioned on the side to prevent aspiration of fluids should the client vomit. An NG tube is not placed after a bronchoscopy because the gastrointestinal tract is not entered. The trachea, not the bowel, can be perforated inadvertently during bronchoscopy; abdominal distention and rigidity would indicate bowel perforation, which is a risk associated with gastrointestinal endoscopy.

A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first? A. A 9-year-old child with a broken leg who wants help moving from the bed to the chair B. An 8-year-old child admitted from the postanesthesia care unit who's complaining of pain C. A 7-year-old child whose mother is waiting for discharge instructions D. A 10-year-old child with asthma whose oxygen saturation levels are dropping

D. A 10-year-old child with asthma whose oxygen saturation levels are dropping Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. The children complaining of pain and waiting for discharge instructions are not life-threatening situations and don't take priority because administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a client from the bed to the chair is also not a life-threatening situation and can be delegated to a nursing assistant.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis? A. Imbalanced nutrition: Less than body requirements B. Impaired urinary elimination C. Excess fluid volume D. Deficient fluid volume

D. Deficient fluid volume Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to fluid volume deficit, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

The nurse is caring for a client with Clostridium difficile infection. Upon entering the room, which of the following steps should the nurse take? A. Take antiseptic wipes into the room. B. Use sterile gloves and foot protection. C. Wear a face mask and goggles. D. Put on an isolation gown and gloves.

D. Put on an isolation gown and gloves. Contact precautions should be implemented when a client has, or is suspected of having, an organism that can be transmitted by direct contact. This can occur when a nurse provides direct care or indirect contact where the organism is transferred to an object and then touched by a person. Contact precautions require that the nurse wear an isolation gown and gloves when entering the room.

The health care provider (HCP) prescribes risperidone for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which behavior? A. concomitant depression B. confusion and withdrawal C. sleep disturbances D. agitation and assaultiveness

D. agitation and assaultiveness Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

A client with bladder cancer has gross hematuria. The client's hemoglobin is 8.0 g/dL (80 g/L), and the health care provider (HCP) prescribes a unit of packed blood cells. The client has an existing intravenous infusion of normal saline using a 19-gauge needle. To administer the packed red blood cells, the nurse should: A. attach the packed blood cells to the existing 22G IV of 5% dextrose using Y tubing. B. start an additional 22G IV site because the packed blood cells must be given in a separate line. C. start an additional IV access device with a 22G intravenous cannulation device. D. attach the packed cells to the existing 19G IV of normal saline solution using Y tubing.

D. attach the packed cells to the existing 19G IV of normal saline solution using Y tubing. The packed cells should be administered using a central catheter or 19G needle. Y tubing and the normal saline solution are used to keep the vein open when the blood transfusion is complete. Blood is not compatible with dextrose because dextrose may cause blood coagulation. Blood products should be given with normal saline solution. A blood filter must be used for all blood products to filter out sediment from stored blood products. It is not necessary to add another IV access.

Which nursing measure will likely decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning? A. monitoring the incision for signs of redness, swelling, and warmth B. accurately measuring drainage from the surgical drainage tube C. inserting an indwelling urinary catheter to prevent possible soiling of the dressing D. changing the surgical dressings using sterile technique

D. changing the surgical dressings using sterile technique Wound infection can best be prevented by using strict sterile technique during dressing changes. Inserting an indwelling urinary catheter is an unnecessary action in this case and would predispose the client to a urinary tract infection. Accurately measuring drainage is an important nursing action but will not prevent a wound infection. Monitoring the incision for signs of infection is an important nursing action but will not prevent a wound infection.

The nurse is preparing to administer a preoperative medication that includes a sedative to a client who is having abdominal surgery. The nurse should first: A. make sure the client is covered with a warm blanket. B. ensure that the operative area has been shaved. C. have the family present. D. have the client empty the bladder.

D. have the client empty the bladder. The nurse should have the client empty the bladder before the premedication is administered. This will be more comfortable and safe for the client. The purpose of the premedication is to decrease anxiety and promote a relaxed state. The client must have an empty bladder before being transferred to the operating room, where the client will be immobilized and receive IV fluids. The family does not have to be present, but it is usually desired. Shaving the operative area is not generally recommended because it can cause small nicks that harbor bacteria. If the client must be shaved, it is usually done in the operating room holding area. The client should be comfortable at all times and offered a warm blanket before or after the premedication.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: A. applying bandages to cover any wounds surgical team members have. B. preoperative cleansing of jewelry worn by the surgical team. C. using sterile surgical scrubs. D. performing a preoperative surgical scrub for at least 3 to 5 minutes.

D. performing a preoperative surgical scrub for at least 3 to 5 minutes. The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.

The nurse should assess a client taking chlorpropamide for: A. dumping syndrome. B. extrapyramidal symptoms. C. oral candidiasis. D. hypoglycemia.

D. hypoglycemia. Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting, and heartburn. The drug does not cause dumping syndrome, oral candidiasis, or extrapyramidal symptoms.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: A. metabolic alkalosis. B. respiratory acidosis. C. respiratory alkalosis. D. metabolic acidosis.

C. respiratory alkalosis. This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

The nurse is planning to initiate a blood transfusion. Which solution should the nurse select to prime the tubing when preparing to administer the blood? A. 5% dextrose in half-normal saline B. lactated Ringer's solution C. 5% dextrose in water D. normal saline

D. normal saline Only isotonic (normal) saline should be used when administering a blood transfusion. The use of dextrose or lactated Ringer's solution will cause the hemolysis of red blood cells.

A client is scheduled for an intravenous pyelogram (IVP). In preparation for the procedure, what should the nurse ask the client? A. "Do you have any allergies?" B. "Have you ever had an IVP before?" C. "Have you ever experienced urinary incontinence?" D. "When was your last bowel movement?"

A. "Do you have any allergies? Before an IVP, the client should be assessed for allergies, particularly to iodine-based dyes that may be used during an IVP. Shellfish is a source of iodine, so people who are allergic to shellfish should inform the health care personnel and ask what type of dye is being used. Asking the client whether he or she has ever had an IVP before can help determine the degree of teaching needed before the procedure, but that is not the most important question. Neither the client's last bowel movement nor urinary incontinence has any relationship to having an IVP.

A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance? A. respiratory acidosis B. metabolic alkalosis C. metabolic acidosis D. respiratory alkalosis

A. respiratory acidosis The pH of 7.26 indicates that the body is in a state of acidosis. The elevated partial pressure of carbon dioxide value accompanied by a normal bicarbonate value indicates that the acid-base imbalance is respiratory acidosis. The additional clinical findings of headache, dizziness, and increased pulse rate, resulting from the elevated partial pressure of carbon dioxide, further support this diagnosis.

What should a nurse do when administering pilocarpine? A. Apply pressure on the outer canthus to prevent adverse reactions. B. Apply pressure on the inner canthus to prevent systemic absorption. C. Flush the client's eye with normal saline solution to prevent burning. D. Administer at bedtime to prevent night blindness.

B. Apply pressure on the inner canthus to prevent systemic absorption. When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

The nurse is teaching the client about home blood glucose monitoring. Which blood glucose measurement indicates hypoglycemia? A. 59 mg/dL (3.3 mmol/L) B. 108 mg/dL (6.0 mmol/L) C. 75 mg/dL (4.2 mmol/L) D. 119 mg/dL (6.6 mmol/L)

A. 59 mg/dL (3.3 mmol/L) Although some individual variation exists, when the blood glucose level decreases to less than 70 mg/dL (3.9 mmol/L), the client experiences or is at risk for hypoglycemia. Hypoglycemia can occur in both type 1 and type 2 diabetes mellitus, although it is more common when the client is taking insulin. The nurse should instruct the client on the prevention, detection, and treatment of hypoglycemia.

A child, just been admitted to the emergency department, has the following chart entry: Progress notes 10/15/16 1800 Parents describe recent weight loss and lack of energy. Client's ears and cheeks are flushed; acetone-smelling breath noted. Blood glucose 324 mg/dl (18.0 mmol/L), BP: 104/60 mmHg; P: 88/bpm; RR: 16 breaths/min. What intervention would the nurse should anticipate? A. Administration of IV regular insulin by continuous infusion pump B. Administration of IV fluids in boluses of 20 ml/kg C. Administration of regular insulin subcutaneously Q4H as needed per sliding scale D. Subcutaneous administration of glucagon

A. Administration of IV regular insulin by continuous infusion pump Weight loss, lack of energy, acetone odor to breath, and a blood glucose level of 324 mg/dl (18.0 mmol/L) would indicate diabetic ketoacidosis. Insulin would be given IV by continuous infusion pump. Glucagon is administered for mild hypoglycemia. Sliding scale insulin isn't as effective as the administration of insulin by continuous infusion pump. Administration of IV fluids in boluses of 20 ml/kg is recommended for the treatment of shock.

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug? A. increased bowel movements B. increased urine output C. nausea and vomiting D. improved level of consciousness

A. increased bowel movements Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose.

When teaching a client with chronic renal failure who is taking antibiotics about signs and symptoms of potential nephrotoxicity to report, the nurse should encourage the client to promptly report which changes in the color of the urine? Select all that apply. A. pink B. cloudy C. straw-colored D. smoky

A. pink B. cloud D. smoky The client who is taking potentially nephrotoxic antibiotics should notify the health care provider (HCP) if the urine is cloudy, smoky, or pink; early signs of nephrotoxicity are manifested by changes in urine color. Straw-colored urine is normal.

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? A. 21 to 25 mcg/ml B. 10 to 20 mcg/ml C. 5 to 10 mcg/ml D. 2 to 5 mcg/ml

B. 10 to 20 mcg/ml The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic. Concentrations above 20 mcg/ml are considered toxic.

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse's priority should be the potential for: A. hyperglycemia. B. aspiration. C. fluid volume excess. D. constipation.

B. aspiration. Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake. Hyperglycemia is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea.

An 11-year-old is admitted for treatment of an asthma attack. Which finding indicates immediate intervention is needed? A. productive cough B. intercostal retractions C. thin, copious mucous secretions D. respiratory rate of 20 breaths/minute

B. intercostal retractions Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and respiration is difficult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can expectorate them, which indicates an improvement in the condition. If the cough is productive it means the bronchospasms and the inflammation have been resolved to the extent that the mucus can be expectorated. A respiratory rate of 20 breaths/minute would be considered normal and no intervention would be needed.

A nurse is caring for an older adult client who is admitted with an electrolyte imbalance. Which laboratory values should be a priority concern for the nurse? Select all that apply. A. PaCO2 45mm Hg B. Sodium 140 mEq/L C. pH 7.32 D. Potassium 5.8 mEq/L E. PaO2 90mm Hg

C. pH 7.32 D. Potassium 5.8 mEq/L The pH value represents the amount of hydrogen ion or concentration of acid in the blood. The normal pH is 7.35-7.45. The CO2 level is still within the normal range. The sodium level is also within the normal range. The normal potassium levels range from 3.5 mEq/L-5.2 mEq/L.

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? A. "On the morning of the surgery, I can shave my surgical area at home to save time." B. "On the morning of surgery, I won't use lotions or cosmetics." C. "I should begin to use an antibacterial soap a few days before my surgical procedure." D. "I'll shower before coming to the hospital on the day of the surgery."

A. "On the morning of the surgery, I can shave my surgical area at home to save time." The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections. Washing with an antibacterial soap for a few days before surgery reduces the skin's bacterial count. The client shouldn't use lotions or cosmetics on the day of the surgery. The client can shower before coming to the hospital

Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? Select all that apply. A. seizures B. central nervous system (CNS) depression C. skin rash D. dry mucous membranes E. urinary incontinence

A. seizures B. central nervous system (CNS) depression E. urinary incontinence An excess of cholinergic agents produces urinary and fecal incontinence, increased salivation, diarrhea, and diaphoresis. In a severe overdose, CNS depression, seizures and muscle fasciculations, bradycardia or tachycardia, weakness, and respiratory arrest due to respiratory muscle paralysis occur. Anticholinergics produce dry mucous membranes. Skin rash is not a sign of overdose with a cholinergic agent.

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis

A. Metabolic alkalosis A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used. A. stop the transfusion B. Notify the HCP and the blood bank C. Keep the IV open with normal saline infusion D. Complete the appropriate transfusion reaction form(s)

A. stop the transfusion C. Keep the IV open with normal saline infusion B. Notify the HCP and the blood bank D. Complete the appropriate transfusion reaction form(s) When the client is having a blood transfusion reaction, the nurse should first stop the transfusion and then keep the IV open with normal saline infusion. Next, the nurse should notify the health care provider (HCP) and blood bank and then complete the required form(s) regarding the transfusion reaction.

A child is being discharged with albuterol nebulizer treatments. The nurse should instruct the parents to watch for: A. tachycardia. B. constipation. C. urine retention. D. bradypnea.

A. tachycardia. Albuterol is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases. Signs and symptoms of albuterol toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, and dizziness. Unusually slow respirations, urine retention, and constipation aren't associated with albuterol toxicity.

The client with Alzheimer's disease has been prescribed donepezil 5 mg at bedtime. Which instruction should the nurse give to the client's daughter? A. Take her mother to the clinic next week for blood work. B. Avoid suddenly stopping the medication. C. Give her mother an extra dose if needed at night. D. Observe her mother for signs of constipation.

B. Avoid suddenly stopping the medication. Abrupt cessation of donepezil may result in rapid deterioration of client functioning. Donepezil does not cause liver toxicity, so monitoring of blood serum levels is not necessary. Extra doses of donepezil are not given on an as-needed basis. Donepezil is more likely to produce diarrhea than constipation.

A child has just received a dose of theophylline I.V. for asthma. What assessment finding should the nurse expect? A. White blood cell count of 12,000 B. Decreased pulmonary wheezing C. Increased coughing because of postnasal drip D. Stridor

B. Decreased pulmonary wheezing Methylxanthines such as theophylline are highly potent bronchodilators used to relieve asthma symptoms. The bronchodilation will result in decreased wheezing. None of the other options are seen after administration of theophylline.

A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? A. "Push or pull an object using your arms." B. "Narrow the stance when lifting." C. "Stand close to the object you're lifting." D. "Bend over the object you're lifting."

C. "Stand close to the object you're lifting." Standing close to an object when lifting moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload.

A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority? A. Encourage the use of the incentive spirometer. B. Monitor blood pressure. C. Assess urine output hourly. D. Check the flank dressing for urine drainage.

C. Assess urine output hourly. After a nephrectomy, a specific aspect of immediate postoperative management includes monitoring urine output at least hourly. Monitoring blood pressure and encouraging the use of incentive spirometry are other important considerations, but because of the surgical disruption of the urinary system, urine output is a priority. Measurement of urine output should also include an estimation of the amount of urine drainage on the flank dressing.

The nurse has asked the unlicensed assistive personnel (UAP) to help with admitting an elderly client who has been diagnosed with bacterial pneumonia. Which activity is appropriate for the nurse to ask the UAP to perform? A. Assess the client's breath sounds. B. Collect nursing history and assessment data. C. Evaluate the client's respiratory status. D. Obtain the client's height and weight.

D. Obtain the client's height and weight. It would be appropriate for the assistant to obtain the client's weight and height. It is the responsibility of the registered nurse to obtain the nursing history, assess the client's breath sounds, and evaluate the client's respiratory status.

A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which of the following? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis

D. Respiratory acidosis An increased level of dissolved carbon dioxide (PaCO2) indicates respiratory acidosis. Metabolic acidosis and alkalosis are not correct because this is a respiratory issue, not a metabolic one. Respiratory alkalosis would have a PaCO2 deficit, not an increase.

A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl (70mmol/L). The most therapeutic pharmacologic intervention would be to administer: A. epoetin alfa. B. enoxaparin. C. filgrastim. D. ferrous sulfate.

A. epoetin alfa. Chronic renal failure diminishes the production of erythropoietin by the kidneys and leads to a subnormal Hb level. (Normal Hb level is 13 to 18 g/dl in men and 12 to 16 g/dl in women.) An effective pharmacologic treatment for this is epoetin alfa, a recombinant erythropoietin. Because the client's anemia is caused by a deficiency of erythropoietin and not a deficiency of iron, administering ferrous sulfate would be ineffective. Neither filgrastim, a drug used to stimulate neutrophils, nor enoxaparin (low-molecular-weight heparin) will raise the client's Hb level.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? A. high-carbohydrate, high-protein B. high-calcium, high-potassium, high-protein C. low-protein, high-potassium D. low-protein, low-sodium, low-potassium

D. low-protein, low-sodium, low-potassium Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.