1210 Exam 1 Set

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A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to a. hold a card and fixate on the center dot. b. report any burning or pain at the IV site. c. remain still while the cornea is anesthetized. d. let the examiner know when images shown appear clear.

ANS: B Fluorescein angiography involves injecting IV dye. If extravasation occurs, fluorescein is toxic to the tissues. The patient should be instructed to report any signs of extravasation such as pain or burning. The nurse should closely monitor the IV site as well. The cornea is anesthetized during ultrasonography. Refractometry involves measuring visual acuity and asking the patient to choose lenses that are the sharpest; it is a painless test. The Amsler grid test involves using a hand held card with grid lines. The patient fixates on the center dot and records any abnormalities of the grid lines.

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take first? a. Apply ice packs to both eyes. b. Flush the eyes with sterile saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

ANS: B Flushing of the eyes immediately is indicated for chemical exposure. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields. Flushing of the eyes immediately is indicated only for chemical exposure. In the case of chemical exposure, the nurse should begin treatment by flushing the eyes until the patient has been assessed by a health care provider and orders are available

23. Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

After teaching a patient with interstitial cystitis about management of the condition, the nurse determines that further instruction is needed when the patient says, a. "I will have to stop having coffee and orange juice for breakfast." b. "I should start taking a high potency multiple vitamin every morning." c. "I will buy some calcium glycerophosphate (Prelief) at the pharmacy." d. "I should call the doctor about increased bladder pain or odorous urine."

ANS: B High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? a. Apply cold compresses at the first sign of recurrence. b. Discard all open or used cosmetics applied near the eyes. c. Wash the scalp and eyebrows with an antiseborrheic shampoo. d. Be examined for recurrent sexually transmitted infections (STIs).

ANS: B Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for sexually transmitted infection (STI) testing

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium level of 120 mg/dL c. Reported weight gain of 2.2 lb (1 kg) d. Urinary output of 280 mL during past 8 hours

ANS: B Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.

19. An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of: a. RDS. b. PIVH. c. BPD. d. ROP.

ANS: B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about a. a low sodium diet. b. ways to avoid falls. c. how to apply sunscreen. d. the chemotherapy side effects.

ANS: B Intermittent vertigo occurs with acoustic neuroma, so the nurse should include information about how to prevent falls. Diet is not a risk factor for acoustic neuroma and no dietary changes are needed. Sunscreen would be used to prevent skin cancers on the external ear. Acoustic neuromas are benign and do not require chemotherapy

54. Which information will the nurse teach a 23-year-old patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is a better choice than whole milk.

ANS: B Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.

21. Following a traumatic birth of a 10-pound infant, the nurse should assess: a. gestational age status. b. flexion of both upper extremities. c. infant's percentile on growth chart. d. blood sugar to detect hyperglycemia.

ANS: B Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infant's growth chart percentile will not provide data about potential injuries from a traumatic birth. A large infant is at risk for hypoglycemia.

1. The nursery nurse should identify which newborn at significant risk for hypothermic alteration in thermoregulation? a. Large for gestational age b. Low birth weight c. Born at term d. Well nourished

ANS: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

Arrange the sequence of events occurring during a fever in chronological order.

(3.)Body temperature is increased., (5.)Heat loss responses are initiated., (1.)Immune system response is triggered., (2.)The set point of the hypothalamus is raised., (4.)Pyrogens are destroyed.

malignant

(adj.) deadly, extremely harmful, evil; spiteful, malicious

Interdisciplinary clinical management of thermoregulation issues; Secondary

(does not apply to this concept)

Hypophosphatemia causes

*Decreased nutritional intake of phosphorus* and malnutrition Use of magnesium-based or *aluminum-hydroxide-based* antacids Renal failure Hyperparathyroidism *Malignancy* *Hypercalcemia* *Alcohol withdrawal* Diabetic ketoacidosis (metabolic acidosis) *Respiratory* alkalosis

15. Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for: a. Hyperglycemia. b. Clavicle fractures. c. Hyperthermia. d. An increase in red blood cells.

ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

oxygen hood

- Small plastic hood that fits over infant's head - Use minimum flow rate (4-5L/min) to prevent CO2 build-up - Ensure neck, chin, shoulders don't rub against hood - Continuous pulse ox

s/s of dehyadration

-<2 mL/kg/hour -increased specific gravity -weight loss -dry skin/ mucus membranes -sunken anterior fontanel -poor tissue turgor -Increased Na, protein, Ht

s/s of overhydration

->5mL/kg/hour output -below normal specific gravity -edema -weight gain -bulging fontanels -moist breath sounds -decreased Na, protein, and Ht

individual risk factors for thermoregulation probs

-Impaired cognition • Genetics • Recreational or occupational exposures • Immobility • Surgery • Alcohol • Substance abuse

Necrotizing Enterocolitis (NEC)

-Occurs in premature and newborn infants. Thought to be infection and or ischemia of the gut. -manifestations: feeding intolerance, increased abd girth, increased gastric residuals, decreased bowel sounds,

thermoregulation

-axillary temp. 36.3-36.9 C -abdominal skin temp <36->36.5 -should be checked every 1-3 hours while stable

Intraventricular hemorrhage

-bleeding around and into the ventricles of the brain -Also called: periventicular-intraventricular hemorrhage, germincal matrix hemorrhage -graded 1-3

feedings

-check for residual volume after giving tube feedings -measure abdominal girth every 4-8 hours

prone position

-encouraged for preterm infants to improve oxygenation and drainage

nutrtion

-fat stores are minimal/absent -at risk for low blood glucose -need approx. 105-130 kcal/kg/day -need protein, iron, calcium, K, Mg -should gain 15-20 g/kg/day

Fluid/ electrolyte balance

-fluid loss occurs easily -kidneys work poorly -risk of Na overload/deficiency -output should be 2-5mL/kg/hour -specific gravity should be 1.002-1.01

feedings LPI

-immature suck/swallow reflexes -sleeping through feedings -shorter awake periods -increased caloric need

Postterm infants

-infants born after 42nd week of gestation -may be up to 4000 g

Respiratory Distress syndrome RDS

-insufficient production of surfactant covering alveoli in the lungs (keeps air sacs open during exhalation) -atelectasis, hypoxia, hypercapnia s/s: tachypnea, nasal flaring, retractions, cyanosis

Bronchopulmonary dysplasia (chronic lung disease)

-lung conditon occuring in infants <28 weeks gestation or <1000g

weaning from heat source

-must be 1500 g/3.5 lbs -consistent weight 5 days -no medical complications -tolerating enteral feedings

Retinopathy of prematurity

-results in visual impairment/blindness in preterm infants -results from injury to retinal blood vessels

readiness for nipple feeding

-rooting -resp rate <60 -increased ability to tolerate holding/handling -sucking -intact gag reflex

minimal enteral feedings

-trophic feedings -few mL of breast milk/formula -feeding tolerance and weight gain improved

oral feedings

-usually ready for oral feedings once they reach what would have been 34-35 weeks gestation

Bilirubin associated ailment prevention

...

Vit K dosage and route

.5mg to 1mg (.25mL to .5mL) 1once intramuscularly within the first hour of birth for prophylaxis. May be repeated or admin higher dose if mother took anticonvulsants

Minimum urine output

0.5 ml/kg/hr or 35 to 70mL/h

Creatinine levels

0.6-1.2 mg/dL

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which medication will the nurse expect the health care provider to prescribe? 1 Calcium 2 Magnesium 3 Bicarbonate 4 Potassium chloride

1 Calcium

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis of nailbeds

1 Crackles in the lungs

The laboratory reports of a client with adrenal adenoma show high urine aldosterone levels and a low specific gravity of urine. The serum potassium is 2.8 mEq/L (2.8 mmol/L). Which other findings will be present on assessment? Select all that apply. One, some, or all responses may be correct. 1 Hypernatremia 2 Hypertension 3 Hypoglycemia 4 Hypercalcemia 5 Metabolic alkalosis

1 Hypernatremia 2 Hypertension 5 Metabolic alkalosis

Intravenous (IV) potassium is prescribed for a client with a diagnosis of hypokalemia. Which statement about administration of IV potassium is accurate? 1 Oliguria is an indication for withholding IV potassium. 2 Rapid infusion of potassium prevents burning at the IV site. 3 Clients with severe deficits should be given IV push potassium. 4 Average IV dosage of potassium should not exceed 60 mEq in 1 hour.

1 Oliguria is an indication for withholding IV potassium.

Treatment of hypothermia (5 things)

1. Manage and maintain ABCs 2. Rewarm patient - remove from cold (active or passive) 3. 100% O2 4. Correct dehydration and acidosis 5. Treat cardiac dysrhythmias (12-lead EKG)

The body temperature of a client with heatstroke is above 104°F (40°C). Which is the priority order the nurse would use for cooling the client so that breathing and circulation are not impaired? 1. The nurse will take off the client's clothing. 2. The nurse would place ice packs on the neck, axillae, chest, and groin. 3. The nurse would immerse the victim in cold water. 4. The nurse would fan the client rapidly to aid in cooling by evaporation.

1.The nurse will take off the client's clothing. 2.The nurse would place ice packs on the neck, axillae, chest, and groin. 3.The nurse would immerse the victim in cold water. 4.The nurse would fan the client rapidly to aid in cooling by evaporation.

BUN levels

10-20 mg/dL

to treat heat stroke, give the pt ____ oxygen

100% oxygen

heat stroke means core temp higher than...

105.8 F

A normal blood sodium level is between ______ and _______ milliequivalents per liter (mEq/L)

135 and 145

Sodium levels

135-145 mEq/L

weighing diapers

1g=1mL

Which action would the nurse take first when a client who is receiving peritoneal dialysis reports difficulty breathing after instillation of dialysate into the peritoneal space? 1 Weigh the client. 2 Check pulse oximetry. 3 Auscultate lung sounds. 4 Reposition the client

2 Check pulse oximetry.

Which nursing intervention would be priority in the period immediately after an emaciated young teenager with anorexia nervosa is admitted to the hospital for starvation? 1 Ensuring that the child's rest and nutrition needs are met 2 Correcting the child's fluid and electrolyte imbalances 3 Obtaining more data about the child's diet and exercise program 4 Completing an assessment of the child's physical and family status

2 Correcting the child's fluid and electrolyte imbalances

Which nursing assessment indicates dehydration in an infant? 1 Flat anterior fontanel 2 Decreased urine output 3 Warm skin temperature 4 Slow, labored respirations

2 Decreased urine output

The nurse is caring for a client who has renal calculi secondary to hyperparathyroidism. Which type of diet would the nurse teach the client? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash

2 Low calcium

Which serum laboratory value in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? 1 Calcium of 9.5 mg/dL (2.375 mmol/L) 2 Potassium of 7.02 mEq/L (7.02 mmol/L) 3 Bicarbonate of 22.8 mEq/L (22.8 mmol/L) 4 Phosphorus of 4.1 mg/dL (1.3243 mmol/L)

2 Potassium of 7.02 mEq/L (7.02 mmol/L)

When monitoring a client for hyponatremia, which assessment findings would the nurse consider significant? Select all that apply. One, some, or all responses may be correct. 1 Thirst 2 Seizures 3 Erythema 4 Confusion 5 Constipation

2 Seizures 4 Confusion

The nurse, caring for a client with full-thickness burns of the anterior trunk and thigh, is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client? 1 Weight every day 2 Urinary output every hour 3 Blood pressure every 15 minutes 4 Extent of peripheral edema every 4 hours

2 Urinary output every hour

HCO3 levels

22-26 mEq/L

Recommended water intake

2300 to 2900 mL

Normal serum osmolality

275-295 mOsm/kg

When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest? 1 Apples 2 Grapes 3 Cantaloupe 4 Cranberries

3 Cantaloupe

The nurse is notified that the latest potassium level for a client who has acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action would the nurse take? 1 Alert the cardiac arrest team. 2 Call the laboratory to repeat the test. 3 Notify the primary health care provider. 4 Obtain an antiarrhythmic medication.

3 Notify the primary health care provider

Which outcome is the main focus of treatment for a client with Addison disease? 1 Decrease in eosinophils 2 Increase in lymphoid tissue 3 Restoration of electrolyte balance 4 Improvement of carbohydrate metabolism

3 Restoration of electrolyte balance

The primary health care provider instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving? 1 Palliative care 2 Comfort care 3 Supportive care 4 End-of-life care

3 Supportive care

a heat exaustive pt may be admitted to the hospital if there is no improvement in ___ hours

3-4

Potassium range

3.5-5

Potassium levels

3.5-5.0 mEq/L

Normally, your blood potassium level is _______ millimoles per liter (mmol/L).

3.6 to 5.2

Normal respirations immediately after birth

30-60/min

The nurse notes that a client has mild hypothermia based on which body temperature?

35°C

Define Hypothermia:

35°C-34°C or 95°F-93.2°F (Exposure) o Brain Injury o Environmental Exposure o Frostbite o Preterm Infant o Submersion o Therapeutic hypothermia

An older adult with chills arrived to the hospital. The nurse assesses the client's vital signs and determined the client has a fever. Which would be the client's rectal temperature?

38.5°C

Define Hyperthermia:

38°C-41°C or 100.4°F-106°F (Environmental vs. Disease Process) o Brain Injury o Febrile seizures o Fever o Heat Exhaustion o Heat Stroke o Hyperthyroidism o Infection: Bacterial/Viral o Malignant Hyperthermia o Thyroid Storm

Which intravenous fluid is a hypertonic solution? 1 Ringer solution 2 5% dextrose in water 3 Lactated Ringer solution 4 5% dextrose in normal saline

4 5% dextrose in normal saline

The nurse provides education for a client who has received a prescription for spironolactone. The information includes a correlation between potassium intake and the medication, and a list of fluids and their potassium content. The nurse concludes that the teaching is effective when the client plans to consume which type of juice? 1 Prune juice 2 Orange juice 3 Tomato juice 4 Cranberry juice

4 Cranberry juice

A client with hyperthyroidism is to receive potassium iodide solution before a subtotal thyroidectomy is performed. Which purpose would the nurse include when explaining why this medication is prescribed? 1 Decreases the total basal metabolic rate 2 Maintains the function of the parathyroids 3 Blocks the formation of thyroxine by the thyroid gland 4 Decreases the size and vascularity of the thyroid gland

4 Decreases the size and vascularity of the thyroid gland

Which action is characteristic of the hormone aldosterone? 1 Helps produce concentrated urine 2 Causes tubular secretion of sodium 3 Promotes potassium secretion in the collecting duct 4 Enhances sodium reabsorption in the distal convoluted tubule

4 Enhances sodium reabsorption in the distal convoluted tubule

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. Which would the nurse suspect as the cause of this weight loss? 1 Viral or bacterial infection 2 Obstructive gastrointestinal anomaly 3 Generalized muscle response to stimulation 4 Imbalance between nutrient intake and fluid loss

4 Imbalance between nutrient intake and fluid loss

An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value would the nurse report to the health care provider? 1 Sodium of 140 mEq/L (140 mmol/L) 2 Ionized calcium of 2.35 mEq/L (1.2 mmol/L) 3 Chloride of 102 mEq/L (102 mmol/L) 4 Potassium of 3.0 mEq/L (3.0 mmol/L)

4 Potassium of 3.0 mEq/L (3.0 mmol/L)odium of 140 mEq/L (140 mmol/L)

The nurse is caring for a client with a temperature of 104.5°F (40.3°C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions? 1 To promote equalization of osmotic pressures 2 To prevent hypoxia associated with diaphoresis 3 To promote integrity of intracerebral neurons 4 To reduce brain metabolism and limit hypoxia

4 To reduce brain metabolism and limit hypoxia

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG

52. After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.

An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

ANS: B Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse

Feed if baby's blood sugar is below

45mg/dL

evaporitive heat loss is ______ times greater w/ wet clothes

WBC levels

5,000-10,000 cells/mm3

Calcium levels

8.5-10.5 mg/dL high: bone pain, muscle weakness, anxiety low: Chovstek and Trousseau's signs, muscle cramps

shivering decreases/disappears at core temp of....

86 F

moderate hypothermia (temp)

86-93 F

stop rewarming once pt's core temp gets to....

90-95 F

mild hypothermia (temp)

93-95 F

normal infant temp

97.7F - 99.5F

Chloride levels

98-106 mEq/L

extremely low birth weight

< 2.3 lbs < 1000 g

very low birth weight

< 3.5 lbs < 1500 g

Hypokalemia levels

<3.5 mEq/L

low birth weight

<5.8 lbs <2500 g

Hyperkalemia levels

>5.0 mEq/L

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "Those symptoms may indicate a need for an increased dosage of the eye drops." b. "The drops are uncomfortable, but it is important to use them to retain your vision." c. "These are normal side effects of the drug, which should be less noticeable with time." d. "Notify your health care provider so that different eye drops can be prescribed for you."

ANS: B Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss. The temporary burning and visual blurriness might not lessen with ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of glaucoma

erythropoietin

A hormone produced and released by the kidney that stimulates the production of red blood cells by the bone marrow. A person with kidney disease may experience anemia bc this hormone stops being produced

Cation

A positively charged ion

Electrolyte

A substance that is dissolved in solution and some of its molecules split or dissociate into electrically charged atoms or ions

deep frostbite

A type of frostbite in which the affected part looks white, yellow-white, or mottled blue-white and is hard, cold, and without sensation.

Older adults have increased vulnerability to kidney injury. Which structural and functional changes in the aging kidney does the nurse recognize as significant risk factors for acute kidney injury in older adults? Select all that apply. a. Fewer nephrons b. Sclerotic glomeruli c. Reduced perfusion d. Increased sodium regulation e. Increased potassium regulation

A,B,C a. Fewer nephrons b. Sclerotic glomeruli c. Reduced perfusion

The nurse is teaching a class for patients who have mild chronic kidney disease. The nurse will tell the class participants that which interventions can help slow the progression to end-stage kidney disease? Select all that apply. a. Nutrition therapy b. Fluid volume control c. Prescription medications d. Mega doses of vitamin C e. Managing blood pressure

A,B,C,E a. Nutrition therapy b. Fluid volume control c. Prescription medications e. Managing blood pressure

Which patients are at risk for acute kidney injury (AKI)? Select all that apply. a. Football player in preseason practice b. Patient who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage d. Accountant with diabetes e. Patient in the intensive care unit on high doses of antibiotics f. Patient recovering from gastrointestinal influenza

A,B,C,E,F a. Football player in preseason practice b. Patient who underwent contrast dye radiology c. Accident victim recovering from a severe hemorrhage e. Patient in the intensive care unit on high doses of antibiotics f. Patient recovering from gastrointestinal influenza

The nurse working in the renal care unit recognizes that which conditions are most likely to result in acute kidney injury related to prerenal perfusion reduction? Select all that apply. a. Anaphylaxis b. Severe dehydration c. Bleeding in the kidney d. Antihypertensive medications e. Use of aspirin, ibuprofen, or nonsteroidal anti-inflammatory drugs (NSAIDs)

A,B,D,E a. Anaphylaxis b. Severe dehydration d. Antihypertensive medications e. Use of aspirin, ibuprofen, or nonsteroidal anti-inflammatory drugs (NSAIDs)

A patient with an acute kidney injury is most often managed in the intensive care unit by an interprofessional health care team. During the acute phase, the team should include which professionals? Select all that apply. a. Pharmacist b. Nephrologist c. Physical therapist d. Nephrology nurse e. Registered dietician f. Occupational therapist

A,B,D,E a. Pharmacist b. Nephrologist d. Nephrology nurse e. Registered dietician

The nurse is caring for a patient with chronic kidney disease. What are some complications the nurse should be aware of after hemodialysis? Select all that apply. a. Infection b. Hypotension c. Weight gain d. Hyperglycemia from dialysate e. Muscle cramps and back pain

A,B,E a. Infection b. Hypotension e. Muscle cramps and back pain

The nurse assesses the reports of a patient suffering from acute kidney injury (AKI). Which parameters indicate the severity of the disease? Select all that apply. a. Decreased urine output b. Increased serum calcium c. Increased serum creatinine d. Decreased glomerular filtration rate e. Decreased blood urea nitrogen (BUN) levels

A,C a. Decreased urine output c. Increased serum creatinine

Which signs and symptoms indicate rejection of a transplanted kidney? Select all that apply. a. Crackles in the lung fields b. Temperature of 98.8°F (37.1°C) c. Blood pressure of 164/98 mm Hg d. +3 edema of the lower extremities e. Blood urea nitrogen (BUN) level of 21 mg/dL; creatinine level of 0.9 mg/dL

A,C,D a. Crackles in the lung fields c. Blood pressure of 164/98 mm Hg d. +3 edema of the lower extremities

While managing care for a patient with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Obtain the patient's predialysis weight. b. Explain the components of a low sodium diet. c. Auscultate the patient's lung sounds every 4 hours. d. Check the arteriovenous (AV) fistula for a thrill and bruit. e. Document the amount the patient drinks throughout the shift.

A,E a. Obtain the patient's predialysis weight. e. Document the amount the patient drinks throughout the shift.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Flush a saline lock with normal saline. b. Verify blood products prior to administration. c. Remove the patient's central venous catheter. d. Titrate the flow rate of vasoactive IV medications.

ANS: A A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer 3% saline at 50 mL/hr for a total of 200 mL. c. Administer IV morphine sulfate 4 mg every 2 hours PRN. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.

ANS: A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Skim milk c. Mixed green salad b. Grape juice d. Fried chicken breast

ANS: A Foods high in phosphate include milk and other dairy products, so these are restricted on low- phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds c. Peripheral pulses b. Urinary output d. Peripheral edema

ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

ANS: A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 U subcutaneously every evening

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin/mineral use d. Over-the-counter (OTC) laxative use

ANS: A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the last magnesium level on the patient's chart. d. Teach the patient about magnesium-containing antacids.

ANS: A The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis c. Respiratory acidosis b. Metabolic alkalosis d. Respiratory alkalosis

ANS: A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

ANS: A The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

ANS: A This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

A 42-year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 30 degrees.

ANS: A A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease. Because the patient will be nauseated during an acute attack, fluids are administered IV. Position changes will cause vertigo and nausea. The head of the bed can be positioned for patient comfort

51. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

26. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

30. A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

When admitting a patient with acute glomerulonephritis, it is most important that the nurse ask the patient about a. recent sore throat and fever. b. history of high blood pressure. c. frequency of bladder infections. d. family history of kidney stones.

ANS: A Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones. DIF: Cognitive Level: Application REF: 1131-1132

25. A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

ANS: A All the nursing diagnoses are appropriate, but because sudden attacks of vertigo can lead to "drop attacks," the major focus of nursing care is to prevent injuries associated with dizziness

5. A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate? a. Use an ultrasound scanner to check the postvoiding residual. b. Monitor the patient's intake and output over the next few hours. c. Have the patient take small amounts of fluid frequently throughout the day. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

ANS: A An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours. DIF: Cognitive Level: Application REF: 1146-1147 | 1154

A 32-year-old patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time? a. Importance of genetic counseling b. Complications of renal transplantation c. Methods for treating chronic and severe pain d. Differences between hemodialysis and peritoneal dialysis

ANS: A Because a 32-year-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain. DIF: Cognitive Level: Application REF: 1143

During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. how long the patient has had the cataract. c. for a white pupil in the patient's right eye. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not affect the perioperative care. Cataract surgery is done using local anesthetics rather than general anesthetics

8. Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

22. A newborn assessment finding that would support the nursing diagnosis of postmaturity would be: a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.

ANS: A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

Which information will the nurse include for a patient contemplating a cochlear implant? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

ANS: A Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

ANS: A Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Skim milk b. Grape juice c. Mixed green salad d. Fried chicken breast

ANS: A Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.

The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A Tono-Pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

ANS: A Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-Pen. The other techniques are used in testing for other eye disorders.

When planning teaching for a patient with benign nephrosclerosis the nurse should include instructions regarding a. monitoring and recording blood pressure. b. obtaining and documenting daily weights. c. measuring daily intake and output amounts. d. preventing bleeding caused by anticoagulants.

ANS: A Hypertension is the major symptom of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis. DIF: Cognitive Level: Application REF: 1141-1142

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first? a. 71-yr-old who has noticed increasing loss of peripheral vision b. 74-yr-old who has difficulty seeing well enough to drive at night c. 60-yr-old who has difficulty hearing clearly in a noisy environment d. 64-yr-old who has decreased hearing and ear "stuffiness" without pain

ANS: A Increasing loss of peripheral vision is characteristic of glaucoma, and the patient should be scheduled for an examination as soon as possible. The other patients have symptoms commonly associated with aging: presbycusis, possible cerumen impaction, and impaired night vision.

A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add a second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

ANS: A Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used

A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? a. "I take metoprolol (Lopressor) for angina." b. "I take aspirin when I have a sinus headache." c. "I have had frequent episodes of conjunctivitis." d. "I have not had an eye examination for 10 years."

ANS: A It is important to note whether the patient takes any -adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.

15. A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient's bed. b. Demonstrate the use of the Credé maneuver to the patient. c. Use an ultrasound scanner to check postvoiding residuals. d. Teach the use of Kegel exercises to strengthen the pelvic floor.

ANS: A Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. DIF: Cognitive Level: Application REF: 1148

The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? a. Discussing the need for sexually transmitted infection testing b. Applying topical corticosteroids to prevent further inflammation c. Assisting with applying for community visual rehabilitation services d. Educating about the use of antiviral eyedrops to treat the infection

ANS: A Patients with AIC have a high risk for concurrent genital Chlamydia infection and should be referred for sexually transmitted infection (STI) testing. AIC is treated with antibiotics. Antiviral and corticosteroid medications are not appropriate therapies. Although some types of Chlamydia infection do cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not appropriate

Which nursing action will be most helpful in decreasing the risk for hospital-acquired infection (HAI) of the urinary tract in patients admitted to the hospital? a. Avoid unnecessary catheterizations. b. Encourage adequate oral fluid intake. c. Test urine with a dipstick daily for nitrites. d. Provide thorough perineal hygiene to patients.

ANS: A Since catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful, but are not as useful as decreasing urinary catheter use. DIF: Cognitive Level: Application REF: 1125-1127

45. A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

3. Decreased surfactant production in the preterm lung is a problem because: a. Surfactant keeps the alveoli open during expiration. b. Surfactant causes increased permeability of the alveoli. c. Surfactant dilates the bronchioles, decreasing airway resistance. d. Surfactant provides transportation for oxygen to enter the blood supply.

ANS: A Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose.

The nurse is assessing a 65-yr-old patient for presbyopia. Which instruction will the nurse give the patient before the test? a. "Hold this card and read the print out loud." b. "Cover one eye while reading the wall chart." c. "You'll feel a short burst of air directed at your eyeball." d. "A light will be used to look for a change in your pupils."

ANS: A The Jaeger card is used to assess near vision problems and presbyopia in persons older than 40 years of age. The card should be held 14 inches away from eyes while the patient reads words in various print sizes. Using a penlight to determine pupil change is testing pupil response. A short burst of air may be used to test intraocular pressure but is not used for testing presbyopia. Covering one eye at a time while reading a wall chart at 20 feet describes the Snellen test.

The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a. The patient has a temperature of 100.6° F. b. The patient complains of "popping" in the ear. c. The patient frequently asks the nurse to repeat information. d. The patient states that the right ear has a feeling of fullness.

ANS: A The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, and decreased hearing are symptoms of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

ANS: A The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss

A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing diagnosis is a priority for the patient? a. Excess fluid volume related to low serum protein levels b. Activity intolerance related to increased weight and fatigue c. Disturbed body image related to peripheral edema and ascites d. Altered nutrition: less than required related to protein restriction

ANS: A The patient has massive edema, so the priority problem at this time is the excess fluid volume. The other nursing diagnoses also are appropriate, but the focus of nursing care should be resolution of the edema and ascites. DIF: Cognitive Level: Application REF: 1133-1135

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective? a. "I will use a sterile catheter and gloves for each time I self-catheterize." b. "I will clean the catheter carefully before and after each catheterization." c. "I will need to buy seven new catheters weekly and use a new one every day." d. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

ANS: B Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics. DIF: Cognitive Level: Application REF: 1154

50. A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

55. Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? a. Ferrous sulfate (Feosol) 325 mg daily b. Senna (Senokot) 1 tablet every day c. Psyllium (Metamucil) 2.1 grams 3 times daily d. Diphenoxylate with atropine (Lomotil) prn loose stools

ANS: B Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

The nurse is performing an eye examination on a 76-yr-old patient. The nurse should refer the patient for a more extensive assessment based on which finding? a. The patient's sclerae are light yellow. b. The patient reports persistent photophobia. c. The pupil recovers slowly after responding to a bright light. d. There is a whitish gray ring encircling the periphery of the iris.

ANS: B Photophobia is not a normally occurring change with aging and would require further assessment. The other assessment data are common gerontologic differences in assessment and would not be unusual in a 76-yr-old patient.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? a. The patient has questions about the ordered eye drops. b. The patient has eye pain rated at a 5 (on a 0 to 10 scale). c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has not improved very much.

ANS: B Postoperative cataract surgery patients usually experience little or no pain, so pain at a level 5 on a 10-point pain scale may indicate complications such as hemorrhage, infection, or increased intraocular pressure. The other information given by the patient indicates a need for patient teaching but does not indicate that complications of the surgery may be occurring

An 88-year-old with benign prostatic hyperplasia (BPH) has a markedly distended bladder and is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Schedule an intravenous pyelogram. c. Administer lorazepam (Ativan) 0.5 mg PO. d. Draw blood for blood urea nitrogen (BUN) and creatinine testing.

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently. DIF: Cognitive Level: Application REF: 1135-1136

48. A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

1. Which is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families with Dependent Children d. Women, Infants, and Children (WIC) nutritional program

ANS: B Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care.

4. A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse? a. Encourage the parents to touch their infant. b. Reassure the parents that the infant is progressing well. c. Discuss the care they will give their infant when the infant goes home. d. Suggest that the parents visit for only a short time to reduce their anxiety.

ANS: A Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infant's progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most important priority during the first visit. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding?

ANS: A When documenting visual acuity, the first number indicates the standard (for normal vision) of 20 feet and the second number indicates the line that the patient is able to read when standing 20 feet from the Snellen chart. OS is the abbreviation for left eye, and OD is the abbreviation for right eye. The remaining three answers do not correctly describe the patient's visual acuity.

The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurse's instructions for this test include asking the patient to a. stand 20 feet away from the wall chart. b. follow the examiner's finger with the eyes only. c. look at an object far away and then near to the eyes. d. look straight ahead while a light is shone into the eyes.

ANS: A When the Snellen chart is used to check visual acuity, the patient should stand 20 feet away. Accommodation is tested by looking at an object at both near and far distances. Shining a pen light into the eyes tests for pupil response. Following the examiner's fingers with the eyes tests extraocular movements.

1. Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Many over-the-counter (OTC) medications can cause constipation. b. Stimulant and saline laxatives can be used regularly. c. Bulk-forming laxatives are an excellent source of fiber. d. Walking or cycling frequently will help bowel motility. e. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient.

ANS: B Problems with balance related to vestibular function may present as nystagmus or vertigo and indicate an increased risk for falls. The Rinne test is used to check hearing. Reading lips and louder speech are compensatory behaviors for decreased hearing.

8. In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Intraventricular hemorrhage (IVH) d. Bronchopulmonary dysplasia (BPD)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue. PTS: 1 DIF: Cognitive Level: Analysis REF: 644 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

6. A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

ANS: B Rinne testing is done using a tuning fork. The other equipment is used for other types of ear examinations.

23. Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation

ANS: A, C, E Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. These infants are at risk for respiratory distress and hypoglycemia.

5. Which strategies should the nurse include in a community program for senior citizens related to dealing with cold winter temperatures? a. Avoiding hot beverages b. Shopping at an indoor mall c. Using a fan at low speed d. Walking slowly in the park

ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? a. "Drink more fluids in the late evening." b. "Increase fluids if your mouth feels dry." c. "More fluids are needed if you feel thirsty." d. "If you feel confused, you need more to drink."

ANS: B An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about extremity numbness or tingling.

ANS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/min. b. There are crackles throughout both lung fields. c. There is sediment and blood in the patient's urine. d. The blood pressure increases from 120/80 to 142/94 mm Hg.

ANS: B Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor c. Urine output b. Daily weight d. Edema presence

ANS: B Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when the patient has a central line." b. "The hypertonic solution will be more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."

ANS: B The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for the past 8 hours. d. There is prolonged skin tenting over the sternum.

ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

ANS: B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor c. Confusion b. Edema d. Restlessness

ANS: B The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action? a. Assign the patient to a semi-private room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves..

ANS: B The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

ANS: B The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.

ANS: B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider's order is not necessary. The patient should turn away from the CVAD during cap changes.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

ANS: B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.

The nurse should report which assessment finding immediately to the health care provider? a. Cone of light is visible. b. Tympanum is blue-tinged. c. Skin in the ear canal is dry and scaly. d. Cerumen is present in the auditory canal.

ANS: B A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be removed before proceeding with the examination but is not unusual or pathologic. The presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal may need further assessment but does not require urgent care.

46. A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

A patient with renal calculi is hospitalized with gross hematuria and severe colicky left flank pain. Which nursing action will be of highest priority at this time? a. Encourage oral fluid intake. b. Administer prescribed analgesics. c. Monitor temperature every 4 hours. d. Give antiemetics as needed for nausea.

ANS: B Although all of the nursing actions may be used for patients with renal lithiasis, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea. DIF: Cognitive Level: Application REF: 1137-1138 | 1139-1141 | 1140

53. The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a. The patient complains of "fullness" in the ear. b. The patient's oral temperature is 100.8° F (38.1° C). c. The patient says "My hearing is worse now than it was right after surgery." d. There is a small amount of dried bloody drainage on the patient's dressing.

ANS: B An elevated temperature may indicate a postoperative infection. Although the nurse would report all the data, a temporary decrease in hearing, bloody drainage on the dressing, and a feeling of congestion (because of the accumulation of blood and drainage in the ear) are common after this surgery

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

ANS: B An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.

9. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation? a. Use of oral opioids for pain control b. Administration of corticosteroid eye drops c. Importance of coughing and deep breathing exercises d. Need for bed rest for the first 1 to 2 days after the surgery

ANS: B Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery. The patient should be able to administer them using safe technique. Pain is not expected after cataract surgery and opioids will not be needed. Coughing and deep breathing exercises are not needed because a general anesthetic agent is not used. There is no bed rest restriction after cataract surgery

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

ANS: B Application of cold and warm packs is included in UAP education and the ability to accomplish this safely would be expected for UAP working in an eye clinic. Medication administration, patient teaching, and assessment are high-level skills appropriate for the education and legal practice level of the RN

18. The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.

10. Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery

35. A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

41. Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

20. A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

Which nursing action should the nurse who is caring for a patient who has had an ileal conduit for several years delegate to nursing assistive personnel (NAP)? a. Assess for symptoms of urinary tract infection (UTI). b. Change the ostomy appliance. c. Choose the appropriate ostomy bag. d. Monitor the appearance of the stoma.

ANS: B Changing the ostomy appliance for a stable patient could be done by NAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for (UTI) symptoms require more education and scope of practice and should be done by the RN. DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158

After obtaining the health history for a 25-year-old who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

ANS: B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by quitting smoking. DIF: Cognitive Level: Application REF: 1145-1146

A patient who has had a transurethral resection with fulguration for bladder cancer 3 days previously calls the nurse at the urology clinic. Which information given by the patient is most important to report to the health care provider? a. The patient is using opioids for pain. b. The patient has noticed clots in the urine. c. The patient is very anxious about the cancer. d. The patient is voiding every 4 hours at night.

ANS: B Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure. DIF: Cognitive Level: Application REF: 1145-1146

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day." b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

ANS: B Contact lenses should not be used when patients have conjunctivitis because they can further irritate the conjunctiva. Hand washing is the major means to prevent the spread of conjunctivitis. Infection may be spread by sharing towels or other contact. It is common for bacterial conjunctivitis to spread through a family or other group in close contact

32. The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turner's signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

14. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Develop a detailed written list of ostomy care tasks for the patient. d. Postpone any teaching until the patient adjusts to the ileostomy.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

33. A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

16. A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A patient with nephrotic syndrome develops flank pain. The nurse will anticipate teaching the patient about treatment with a. antibiotics. b. anticoagulants. c. corticosteroids. d. antihypertensives.

ANS: B Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis. DIF: Cognitive Level: Application REF: 1133-1134

When a client is admitted to the emergency department with disseminated intravascular coagulation caused by sepsis, which prescribed action will the nurse take first? a) Apply antiembolism stockings. b) Draw blood for culture and sensitivity. c) Administer vancomycin 1 gram intravenously. d) Transfer the client to the intensive care unit.

b) Draw blood for culture and sensitivity. - Treatment of disseminated intravascular coagulation focuses on treatment of the cause of the abnormal coagulation, so rapid initiation of antibiotic therapy is essential. However, blood cultures are drawn before antibiotic administration to ensure that appropriate antibiotics can be prescribed. Antiembolism stockings are needed to help prevent venous thrombosis, but are not the priority action. The client needs to be transferred to the intensive care unit, but the nurse would not wait for the transfer to obtain cultures and administer antibiotics.

The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How would the nurse explain the increased risk for hypothermia in preterm infants? a) Have a smaller body surface area than full-term newborns b) Lack the subcutaneous fat that usually provides insulation c) Perspire excessively, causing a constant loss of body heat d) Have a limited ability to produce antibodies against infections

b) Lack the subcutaneous fat that usually provides insulation - Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and has little of this insulating layer. The preterm infant has a relatively larger surface area per body weight than does a term infant. Preterm infants do not shiver or perspire. Depressed antibody production is unrelated to maintenance of body temperature.

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? a) slow heart rate b) cool skin temperature c) bounding radial pulse d) increase urine output

b) cool skin temperature - Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion. Tachycardia, not bradycardia (slow heart rate), occurs as a compensatory mechanism in hypovolemic shock. The pulses in hypovolemic shock are weak and thready because of decreased blood pressure. Urine output will decrease because of decreased kidney perfusion in hypovolemic shock.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? a) Axilla b) oral cavity c) temporal artery d) tympanic membrane

b) oral cavity - The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances would the client have? Select all that apply. One, some, or all responses may be correct. a) Cortisol b) thyroid c) estrogen d) testosterone e) progesterone

b) thyroid d) testosterone - Body temperature is assessed during physical assessment. An increased basal metabolic rate (BMR) increases the body temperature. Hormonal imbalances may alter the BMR. Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR.

The registered nurse teaches a student nurse about caring for patients with polyuria associated with an acute kidney injury (AKI). What statement made by the student nurse indicates the need for further teaching? a. "Polyuria is a sign of recovery from acute kidney injury." b. "Acute kidney injuries are always associated with polyuria." c. "Polyuria associated with an acute kidney injury is due to the holding of fluid in the filtrate by the proteins." d. "The etiology of polyuria in an acute kidney injury is associated with inflammatory causes."

b. "Acute kidney injuries are always associated with polyuria."

The nurse receives the change-of-shift report on four patients. Which patient does the nurse decide to assess first? a. 26-year-old admitted 2 days ago with urosepsis and an oral temperature of 99.4° F (37.4° C) b. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours c. 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for a cystoscopy d. 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

b. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours

The nurse is caring for a dialysis patient with a very poor appetite. What action does the nurse take? a. Allow dietary potassium intake up to 90 mEq. b. Administer total parenteral nutrition as prescribed. c. Provide 40 g/day of prescribed protein in the diet. d. Allow fluid intake equal to urine output plus 200 mL.

b. Administer total parenteral nutrition as prescribed.

A patient with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? a. Assess for crackles. b. Auscultate for pericardial friction rub. c. Monitor for decreased peripheral pulses. d. Determine if the patient is able to ambulate.

b. Auscultate for pericardial friction rub.

The nurse notices a brown-colored effluent in the drainage bag of a patient undergoing peritoneal dialysis. What should the nurse infer from this finding? a. Infection b. Bowel perforation c. Bladder perforation d. Internal hemorrhage

b. Bowel perforation

What is the nurse's priority when caring for a patient with polycystic kidney disease (PKD)? a. Monitoring fluid balance b. Controlling hypertension c. Maintaining electrolyte balance d. Monitoring for ruptured aneurysms

b. Controlling hypertension

What action by the patient during contrast imaging may prevent complications? a. Using antibiotics b. Having a check of serum creatinine c. Using nonsteroidal anti-inflammatory drugs d. Reducing water intake before injecting contrast dye

b. Having a check of serum creatinine

The nurse is caring for a patient with complications of chronic kidney disease. Which alteration in laboratory values does the nurse expect to see with this patient? a. Increased serum calcium b. Increased serum creatinine c. Decreased serum potassium d. Decreased serum phosphorus

b. Increased serum creatinine

Which medication is most effective in slowing the progression of kidney failure in a patient with chronic kidney disease? a. Diltiazem b. Lisinopril c. Clonidine d. Doxazosin

b. Lisinopril

The nurse is reviewing the reports of a patient suffering from septic shock. The investigation data is given below. What would the nurse conclude based on these findings? a. Intrinsic acute kidney injury b. Prerenal acute kidney injury c. Intrarenal acute kidney injury d. Postrenal acute kidney injury

b. Prerenal acute kidney injury

A patient with end stage kidney disease (ESKD) while undergoing hemodialysis is placed on a diet restricted in sodium, potassium, phosphorous, fluids, and proteins. Which part of this diet would lead to muscle wasting? a. Fluid restricted diet b. Protein restricted diet c.Sodium restricted diet d. Phosphorous restricted diet

b. Protein restricted diet

A patient admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the patient? a. RN who has floated from pediatrics for this shift b. RN who usually works on the general surgical unit c. LPN/LVN with experience working on the medical unit d. New graduate RN who just finished a 6-week orientation

b. RN who usually works on the general surgical unit

A patient receiving hemodialysis is prescribed folic acid and ferrous sulfate orally. What does the nurse teach the patient about folic acid therapy? a. Do not take stool softeners. b. Take the drug after dialysis. c. Report any change in the color of stool. d. Avoid antacids within 2 hours of taking folic acid.

b. Take the drug after dialysis.

*3. The immunologic mechanisms involved in acute poststreptococal glomerulonephritis include:* a. tubular blocking by precipitates of bacteria and antibody reactions b. deposition of immune complexes and complement along the GBM c. thickening of the GBM from autoimmune microangiopathic changes d. destruction of glomeruli by proteolytic enzymes contained in the GBM

b. deposition of immune complexes and complement along the GBM

*10. A patient with ureterolithotomy returns from surgery with a nephrostomy tube in place. Postoperative nursing care of the patient includes:* a.encourage the patient to drink fruit juices and milk b.encouraging fluids of at least 2-3 L/day after nausea has subsided c. irrigating the nephrostomy tube with 10ml of NS solution as needed d. notifying the physician if nephrostomy tube drainage is more than 30ml/hr

b.encouraging fluids of at least 2-3 L/day after nausea has subsided

*8. The nurse identifies a risk factor for kidney and bladder cancer in a patient who relates a history of* a.aspirin use b.tobacco use c.chronic alcohol abuse d.use of artificial sweeteners

b.tobacco use

*2. The nurse teaches the female paitent who has frequent UTIs that she should* a. take tub baths with bubble bath b.urinate before and after sexual intercourse c.take prophylactic sufonamides for the rest of her life d. restrict fluid intake to prevent the need for frequent voiding

b.urinate before and after sexual intercourse

severe hypothermia (temp)

below 86 F

_______'s will form w/in hours in a place where there is frost bite

blisters

Hepatic function. related to what levels

blood glucose and bilirubin conjugation

evaportive heat loss increases to 25 greater than normal when.....

body is immersed in cold water

heat stroke causes swelling of the ____

brain

Rhabomyolysis

breakdown of muscle fibers; may be caused by heatstroke or heavy exercise

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? a) Urine output 1000 mL in 8 hours b) Oral temperature 101°F (38.3°C) c) Client report of feeling very thirsty d) Bounding radial and femoral pulses

c) Client report of feeling very thirsty - With hypovolemic shock, extravascular fluid depletion leads to client feeling of thirst. With hypovolemia, urine output will decrease due to compensatory mechanisms designed to retain volume. Elevated temperature might occur with septic shock, but temperature may be lower with hypovolemia because of poor perfusion. With hypovolemia, pulses would be weak.

Which changes that occur with aging increase the risk for hypothermia in older adults? Select all that apply. One, some, or all responses may be correct. a) Increased metabolic rate b) Increased shivering response c) Decreased amount of body fat d) Diminished energy reserves e) Chronic medical conditions

c) Decreased amount of body fat d) Diminished energy reserves e) Chronic medical conditions - Many older adults have decreases in body fat, diminished energy reserves, and chronic medical conditions that increase the risk for hypothermia when exposed to cold. Metabolic rate slows with aging, which increases hypothermia risk. The shivering response to cold decreases with age, and this increases hypothermia risk.

When a client with hypovolemic shock has a hematocrit value of 25%, which fluid therapy will the nurse prepare to infuse? a) Lactated Ringer solution b) Human serum albumin 5% c) Packed red blood cells d) High molecular weight dextran

c) Packed red blood cells - Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. The other three fluids will increase volume, but will not improve the oxygen-carrying capacity of the blood. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? a) Decreased rate of glomerular filtration b) Excessive blood loss through the burned tissues c) Plasma proteins moving out of the intravascular compartment d) Sodium retention occurring as a result of the aldosterone mechanism

c) Plasma proteins moving out of the intravascular compartment - The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

Which nursing intervention would prevent septic shock in the hospitalized client? a) Maintain the client in a normothermic state. b) Administer blood products to replace fluid losses. c) Use aseptic technique during all invasive procedures. d) Keep the critically ill client immobilized to reduce metabolic demands.

c) Use aseptic technique during all invasive procedures. - Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

A patient is scheduled to undergo kidney transplant surgery. Which teaching point would the nurse include preoperatively? a. "Your diseased kidneys will be removed at the same time the transplant is performed." b. "The new kidney will be placed directly below one of your old kidneys." c. "It will be essential for you to wash your hands and avoid people who are ill." d. "You will receive dialysis the day before surgery and for about a week after."

c. "It will be essential for you to wash your hands and avoid people who are ill."

The nurse provides post-dialysis care to a patient. How much protein is required per day if the patient's body weight is 60 kg? a. 25 gm/day b. 50 gm/day c. 75 gm/day d. 100 gm/day

c. 75 gm/day Rationale: Patients undergoing dialysis require 1 to 1.5 g/kg of protein intake per day to compensate for any protein lost during dialysis. For a patient weighing 60 kg, the protein intake is calculated to be 60 to 90 (average 75) gm/day. Fewer than 60 gm will result in protein depletion. More than 90 gm will lead to excess protein, which may lead to renal failure.

Which patient is more susceptible to acute kidney injury (AKI)? a. A patient suffering from fever b. A patient suffering from anemia c. A patient suffering from hypertension d. A patient who has sustained a humerus fracture

c. A patient suffering from hypertension

Which patient with end stage kidney disease is an ideal candidate for hemodialysis? a. An 80-year-old patient with hypertension b. A patient with a hemoglobin level of 6 mg/dL c. A patient who just had surgery for appendicitis d. A patient with an immature arteriovenous (AV) fistula

c. A patient who just had surgery for appendicitis

Which parameter should be considered normal in a patient who underwent renal transplantation 48 hours ago? a. Oliguria b. Diuresis c. Blood-tinged urine d. Presence of acetone bodies in urine

c. Blood-tinged urine

A patient suffering from acute kidney injury has difficulty breathing and pitting peripheral edema. In addition, crackling sounds are heard on auscultation. Which treatment is inappropriate? a. Hemodialysis b. Hemofiltration c. IV fluid infusion d. Administration of diuretics

c. IV fluid infusion

Which clinical manifestation may be evident in the initial stage of hypovolemic shock? a. Decrease in urine output b. Decrease in cardiac output c. Increase in heart and respiratory rate d. A 2%-5% decrease in oxygen saturation

c. Increase in heart and respiratory rate

What is the primary nursing intervention for a patient with an acute kidney injury who has increased blood osmolarity? a. Hemodialysis b. Peritoneal dialysis c. Isotonic saline infusion d. Administration of diuretics

c. Isotonic saline infusion

What pretreatment should be given to a patient with a known history of renal failure while administering ibuprofen? a. Oral or intravenous antibiotics b. Oral or intravenous diuretic medication c. Oral or intravenous bolus of fluid volume d. Oral or intravenous H 2 receptor antagonist

c. Oral or intravenous bolus of fluid volume

The nurse is caring for a patient with a peritoneal dialysis catheter. What action does the nurse take? a. Clean the area twice with cotton swabs. b. Use clean technique while cleaning the site. c. Remove the old dressing and assess the area for infection. d. Clean the site from the abdomen toward the insertion site.

c. Remove the old dressing and assess the area for infection.

When caring for a patient with acute kidney injury (AKI) and a temporary subclavian hemodialysis catheter, which assessment finding would the nurse report to the provider immediately? a. Anorexia b. +1 ankle edema c. Temperature of 100.8°F d. Mild discomfort at the catheter insertion site

c. Temperature of 100.8°F

When caring for a patient who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? a. Pulse oximetry reading of 95 percent b. Blood pressure of 148/90 mm Hg c. Temperature of 101.2°F (38.4°C) d. Sinus bradycardia, rate of 58 beats/min

c. Temperature of 101.2°F (38.4°C)

While assisting a patient during peritoneal dialysis, the nurse observes the drainage discontinue after 200 mL of peritoneal effluent. What action should the nurse implement first? a. Reposition the catheter. b. Document the effluent as output. c. Turn the patient to the opposite side. d. Instruct the patient to deep breathe and cough.

c. Turn the patient to the opposite side.

indications for hypotonic solution

cellular fluid replacement diabetic ketoacidosis some calories hyperglycemic state

dextrose solutions higher than 10% should be given via......except

central vein 50% dextrose which can be given in small amts via peripheral vein to correct hypoglycemia

extracellular fluid major anion (2)

chloride phosphorus

Anion (4 negative)

chloride Cl- bicarbonate HCO3- phosphate PO4- sulfate SO4-

patients receiving hypertonic solution must be monitored for

circulatory overload due to increase in ECF volume

sepsis

common in preterm infants b/c of invasive procedures, exposure to maternal infection, lack of IgG from mother in 3rd trimester

osmolality vs tonicity

concentration of solutes providing pressure in body fluid

Systemic Hypothermia

core body temperature below 35C

indications for isotonic solutions

corrects dehydration replaces gi loss some calories

Types of IV solutions

crystalloids colloids blood and products lipid emusion

3 general types of IV solutions for fluid replacement

crystalloids (with and without added electrolytes) colloid blood and blood products

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop? a) Increased basal metabolic rate b) Decreased involuntary shivering c) Increased voluntary movements d) Decreased nonshivering thermogenesis

d) Decreased nonshivering thermogenesis - Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism's failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

Which activity places a client at risk for hyperthermia? a) Snowmobiling b) Skiing in the winter c) Hiking Alaskan mountains d) Performing strenuous activity in high humidity

d) Performing strenuous activity in high humidity - When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

Which action would be the nurse's priority of care for a client with hypothermia? a) Administering electrolytes b) Monitoring body temperature c) Increasing the temperature of the room d) Removing the client from the cold environment

d) Removing the client from the cold environment - Hypothermia is associated with a decrease in core body temperature, which requires interventions that lead to an increase in the client's internal body temperature. The client should be first removed from the cold environment. Electrolytes should be administered once the client's temperature is controlled. Monitoring the client's temperature is performed during ongoing assessments after providing initial treatment. Increasing the room temperature should be done after the client is removed from the cold environment.

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? a) Respirations of 10 b) Urine output of 30 mL/hour c) Lethargy d) Restlessness

d) Restlessness - In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.

Which statement reflects understanding of sepsis screening requirements by the nurse? a) Blood cultures are required to diagnosis sepsis and begin sepsis protocols. b) An oral temperature of 96.4°F (35.8°C) is not an indicator of sepsis. c) A primary health care provider's prescription is required to screen for sepsis. d) Sepsis mortality is affected greatly by treatments performed in the first 6 hours.

d) Sepsis mortality is affected greatly by treatments performed in the first 6 hours. - Studies have shown that if a bundle treatment is not performed in the first 6 hours, the likelihood of survival dramatically decreases. Only in about 30% to 40% of the cases are blood cultures positive in septic clients; this is because in many cases sepsis works faster than the laboratory can produce the result using the current technology. Hypothermia is as strong a sepsis indicator as hyperthermia; however, the health care team members often miss this symptom. The signs and symptoms of sepsis are not specific and may indicate many other diseases as well. If the health care team is not actively looking for sepsis, it will be missed. A sepsis screening is an assessment that the nurse can perform at any time. To perform the screening, the nurse analyzes the vital signs, client history, and laboratory reports; the nurse synthesizes the findings to evaluate if sepsis screening is negative or positive and then notifies the primary health care provider of the findings.

The nurse is caring for a client with a temperature of 104.5°F (40.3°C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions? a) To promote equalization of osmotic pressures b) To prevent hypoxia associated with diaphoresis c) To promote integrity of intracerebral neurons d) To reduce brain metabolism and limit hypoxia

d) To reduce brain metabolism and limit hypoxia - Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

The registered nurse is teaching a student nurse about the usage of long-term dialysis catheters. Which statement by the student nurse about the placement of a long-term dialysis catheter needs correction? a. "Septicemia is a complication." b. "The catheter is placed using tunneling technique." c. "Sedation is needed for the placement of the catheter." d. "A tunnel measuring 10 cm is made subcutaneously."

d. "A tunnel measuring 10 cm is made subcutaneously."

The nurse is teaching a patient with acute kidney injury how to take prescribed ferrous sulfate. What statement made by the patient indicates a need for further teaching? a. "I have to take the drug after dialysis." b. "The drug should be taken along with meals." c. "I must take a stool softener daily along with this drug." d. "My pulse should be taken daily before I take this drug."

d. "My pulse should be taken daily before I take this drug."

Which question from the nurse to the interdisciplinary health care team may result in reducing incidence of hospital-acquired acute kidney injury (AKI)? a. "Should we filter air circulation?" b. "Should we decrease intravenous fluid rates?" c. "Should we add low-dose dopamine to the treatment regimen?" d. "Should we use less radiographic contrast dye?"

d. "Should we use less radiographic contrast dye?"

A patient is being treated for kidney failure. Which statement by the nurse encourages the patient to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? a. "Are you afraid of dying?" b. "How are you doing this morning?" c. "All of this is new. What can't you do?" d. "What concerns do you have about your kidney disease?"

d. "What concerns do you have about your kidney disease?"

he caregiver of a patient receiving dialysis reports increased fatigue in the patient. What does the nurse suggest to the caregiver? a. Avoid giving the patient iron supplements. b. Provide vitamin supplements before dialysis. c. Provide 0.55 to 0.60 g of protein per kg of body weight. d. Administer subcutaneous erythropoietin as prescribed.

d. Administer subcutaneous erythropoietin as prescribed.

A patient with a recently created vascular access for hemodialysis is being discharged. Which information would the nurse include in discharge teaching in order to prevent complications with the graft? a. How to practice proper nutrition b. How to assess for a bruit in the affected arm c. Modifications to allow for complete rest of the affected arm d. Avoiding venipuncture and blood pressure measurements in the affected arm

d. Avoiding venipuncture and blood pressure measurements in the affected arm

To prevent prerenal acute kidney injury, which person is encouraged to increase fluid consumption? a. Taxicab driver b. Schoolteacher c. Office secretary d. Construction worker

d. Construction worker

A patient suffering from acute kidney injury reports a loss of appetite, nausea, vomiting, itching, and white salt-like frosty deposits on the skin. What diet would the nurse suggest? a. Fiber-rich diet b. Protein rich diet c. Glucose infusion d. Fat emulsion infusion

d. Fat emulsion infusion

For which systemic, metabolic complications does the nurse monitor the patient who is admitted with an acute kidney injury? a. Anemia b. Pneumonia c.Malnutrition d. Hyponatremia

d. Hyponatremia

What statement is true about interventions provided to patients with acute kidney injury (AKI)? a. Ibuprofen is the preferred analgesic for patients with acute kidney injury (AKI). b. Metformin is used to treat diabetes in patients with acute kidney injury (AKI). c. Iodinated dyes are used for imaging techniques in patients with acute kidney injury (AKI). d. IV isotonic saline infusion is the primary treatment intervention in hypovolemic patients with acute kidney injury (AKI).

d. IV isotonic saline infusion is the primary treatment intervention in hypovolemic patients with acute kidney injury (AKI).

Which clinical manifestation indicates the need for increased fluids in a patient with kidney failure? a. Pale-colored urine b. Decreased sodium level c. Increased creatinine level d. Increased blood urea nitrogen (BUN)

d. Increased blood urea nitrogen (BUN)

The nurse is caring for a patient who underwent placement of an arteriovenous fistula. What is the priority postoperative intervention for this patient? a. Monitor blood pressure in the extremity. b. Palpate the area for thrills every 2 hours. c. Start an IV line in the extremity with the fistula. d. Instruct the patient to elevate the extremity postoperatively.

d. Instruct the patient to elevate the extremity postoperatively.

A patient with chronic kidney disease sustained a fall at home. The imaging and laboratory reports revealed multiple fractures, spinal sclerosis, decreased bone density, decreased serum calcium levels, and elevated serum phosphorous levels. Which diagnosis is the nurse most likely to expect for this patient? a. Osteopenia b. Osteomyelitis c. Osteoporosis d. Osteodystrophy

d. Osteodystrophy

The urine output of four patients undergoing treatment for acute kidney injury (AKI) is given below. Which patient's finding should be reported immediately to the health care provider? a. Patient A b. Patient B c. Patient C d. Patient D

d. Patient D

The nurse provides care for a patient admitted with an acute kidney injury as the result of thoracic and abdominal trauma sustained in a motor vehicle accident. For which cardiovascular complications does the nurse monitor the patient? a. Bleeding b. Thrombosis c. Hypocalcemia d. Pulmonary embolism

d. Pulmonary embolism

When taking the health history of a patient with acute glomerulonephritis, the nurse questions the patient about which related cause of the problem? a. Hypertension b. Neoplastic disease c. Unexplained weight loss d. Recent respiratory infection

d. Recent respiratory infection

Which nursing intervention should be performed to relieve a patient's pain during the inflow of the dialysate during peritoneal dialysis? a. Cool the dialysate in the refrigerator. b. Heat the dialysate using a heating pad. c. Warm the dialysate in a microwave oven. d. Warm the dialysate using a warming chamber.

d. Warm the dialysate using a warming chamber.

*1. In teaching a patient with pyelonephritis about the disorder, the nurse informs the paitent that the organisms that cause pyelonephritis most commonly reach the kidneys through* a. the bloodstream b.the lymphatic system c. a descending infection d. an ascending infection

d. an ascending infection

*11. A patient has has a cystectomy and ileal conduit diversion performed. Four days postoperatively, mucous shred are seen in the drainage bag. The nurse should.* a. notify the physician b.notify the charge nurse c. irrigate the drainage tube d. chart it as a normal observation

d. chart it as a normal observation

*7. The nurse recommends genetic counseling for the children of a patient with* a.nephrotic syndrome b.chronic pyelonephritis c. malignant nephrosclerosis d.adult onset polycystic kidney disease

d.adult onset polycystic kidney disease

*5.The edema that occurs in nephrotic syndrome is due to* a. increased hydrostatic pressure caused by sodium retention. b. decreased aldosterone secretion from adrenal insufficiency. c. increased fluid retention caused by decreased glomerular filtration d.decreased colloidal osmotic pressure caused by loss of serum albumin

d.decreased colloidal osmotic pressure caused by loss of serum albumin

shoulder dystocia

delayed or difficult birth of the fetal shoulders after the head is born

osmolality

describes the concentration of body fluids

crystalloid volume expanders

dextran albumin hetastarch

example of crystalloid

dextrose normal saline lactated

cause of hyperosmolality

diarrhea increased salt and solute (protein) inadequate water intake diabetes or ketoacidosis sweating

Dyspnea

difficult or labored breathing

respiratory distress syndrome

difficulty breathing due to lack of surfactant for alveoli; occurs especially in preterm infants

Nursing implementations for Excess sodium

dilute with sodium-free IV fluids and promote sodium excretion with diuretics

Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct. a) seizures b) diaphoresis c) flushed skin d) poor feeding e) hypoglycemia

e) hypoglycemia - Hypoglycemia in a newborn can indicate hypothermia or cold stress. Seizures, diaphoresis, flushed skin, and poor feeding are indicative of hyperthermia.

A patient suffering from acute kidney injury (AKI) due to prerenal causes reports reduced urine volume. Arrange the pathophysiology involved in AKI in chronological order. a. Activation of renin b. Activation of angiotensin I c. Reabsorption of Na +2 d. Activation of aldosterone e. Conversion of prorenin to renin f .Activation of angiotensin II g. Activation of angiotensinogen

e. Conversion of prorenin to renin a. Activation of renin g. Activation of angiotensinogen b. Activation of angiotensin I f .Activation of angiotensin II d. Activation of aldosterone c. Reabsorption of Na +2

most common frost bite places on the body

ears, nose, fingers, toes

when recoveing from heat storke, what labs to monitor?

electrolyte (bc of intense sweating) + coagulation

long term use of hypertonic solution can lead to

electrolyte depletion increased vascular volume fluid overload water intoxication pulmonary edema

cause of hypoosmolality

excess water or edema

hypercapnia

excessive carbon dioxide in the blood

compliance

excessive compliance of newborns chest cage during retractions can interfere w/ lung expansion

Hyperkalemia

excessive potassium in the blood

nursing diagnosis: Risk for Disorganized Infant Behavior related to stress from an overstimulating environment

expected outcomes: the infant will show decreasing signs of overstimulation during routine activity, as evidenced by fewer respiratory and behavioral changes during handling and increased periods of relaxed behavior or sleep

Identify the clinical manifestations associated with inhalation anthrax? Select all that apply. One, some, or all responses may be correct.

fatigue, fever, dry cough

hypoosmolar weight

fewer particles than water

FVD

fluid volume deficit

heat cramps usually resolve with....

fluid, electrolyte replacement, plus rest

heat exhaustion treatment

fluid/electrolyte replacement + place a moist sheet over them to reduce core temp

Foods high in potassium

fruits, fruit juice, vegetables

for pt's w/ heat stroke, place ice packs....

groins, axilla, back of neck

early sign of heat stress

heat + nausea (sit down if you feel nauseous in the heat)

feeling of anxiety are normal when experiencing....

heat exhaustion

____ may cause tachycardia, tachypnea

heat stroke

if heat exhaustion is not resolved, it turns into...

heat stroke

the most serious type pf heat stress

heat stroke - med emergency

excessive infusion of hypotonic solution could cause

hemolysis decreased blood pressure decreased IVF

Common Colloid Solutions

high molecular dextran 70 -6% low molecular weight dextran 40 hetastarch 6% (like human albumin) albumin 5% and 25% (blood product)

hypotonic solutions used for

hydration hyperosmolar diabetes

isotonic solution used for

hydration expand ECF volume (fluid remains In intravascular space)

HCO3-

hydrogen carbonate (bicarbonate) ion

most electrolytes interact with ....... .to maintain acid base balance

hydrogen ions

rapid infusion of dextrose solution may cause

hyperglycemia which can lead to osmotis diuretics, fluid and electrolyte imbalance

rapid infusion of isotonic saline can lead to

hypernatremia fluid volume excess electrolyte depletion

3% saline tonicity

hypertonic

5% dextrose in 0.45% normal saline tonicity

hypertonic

5% dextrose in 0.9% saline tonicity

hypertonic

D10W tonicity

hypertonic

Chvostek's sign is associated with....

hypocalcemia

Thermoregulation is a complex process controlled by the ___________ involving compensatory and regulatory actions to maintain core temperature

hypothalamus

0.45% saline tonicity

hypotonic

tissue freezing leads to _______ in tissue

ice crystals

indications for hypertonic solution

increases serum osmolality severe hyponatremia some calories

fetal growth restriction

infants that have failed to grow in the uterus as expected

small-for-gestational age

infants who fall below the 10th percentile in size on growth charts

large-for-gestational age

infants with a weight above the 90th percentile for gestational age

ECF (extracellular fluid) divided into 3 sub compartments

interstitial -bathes and surrounds cells intravascular -contains plasma & blood vessels transcellular (aka third space) - contains mucus & gastrointestinal, cerebrospinal, pericardial,synovial and ocular fluids

adult body fluid volume

intracellular 40% extracellular 20% - interstitial. 15% - intravascular 5% - transcellular 1-2 L total,nt added total body fluid 60%

caution with hypotonic solution

intracranial pressure liver disease shock or trauma burns monitor for signs of FVD, worse hypovolemia

0.9% saline tonicity

isotonic

5% Dextrose in 0.25% NS tonicity

isotonic

Lactated Ringer's Solution tonicity

isotonic

Ringer's Solution tonicity

isotonic

what solution is used got hydration, expand ECF and during blood product transfusion

isotonic

3 major classifications of crystalloid IVF

isotonic hypotonic hypertonic

Crystalloid fluids

isotonic, hypotonic, hypertonic

pruritus

itching

examples.of isotonic solutions

lactated ringers ringers solution 0.9 sodium chloride 5% dextrose

macrosomia

large-bodied baby commonly seen in diabetic pregnancies; weigh more than 4000g

metabolic acidosis

low pH, low HCO3

the skin looks _____ in cold injury

modeled, yellow/blue, tingling, numb, burning

hyperosmolar weight

more particles than water

Hyperkalemia causes

most common in renal failure High serum potassium caused by Impaired renal excretion Shift from ICF to ECF Massive intake of potassium Some drugs

Heat cramps

muscle spasms that result from a loss of large amounts of salt and water through perspiration

does normal saline contain calories

The nurse concludes that a client with a body temperature of 98.6°F is experiencing which condition?

normothermia

Osmole

number of solutes in a solution

Objective signs of impaired thermoregulation

o Presenting symptoms of hypo- or hyperthermia o Vasoconstriction or vasodilation o Alterations in vital signs (tachycardia, blood pressure, cardiac output) o Muscle rigidity o Flushed skin without diaphoresis

number of particles dissolved in serum (primarily sodium urea (bun) and glucose is called

osmolality

heat exhaustion may cause the skin to be.....

pale, ashen color - but also a red or pink may be present because of vasodilation

what are refractory cases when treating pt's w/ heat emergencies?

peritoneal, rectal, or bladder lavage w/ ice water, also using COLD air for ventilation, use of COLD IV fluids

why is dextrose irritating to veins

ph (3.4 to 4)

What serum blood level is decreased in patients with parathyroidism?

phosphate

intracellular fluid major anion (1)

phosphorus

Vit K1, alt names

phytonadione, aquaMEPHTON, Konakion, Mephyton ANTIHEMMORAGIC coagulant

Signs of hypocalcemia include

positive Chvostek's sign positive Triusseau's sign muscle spasms tingling in lips and fingers

every time there is cell damage, _______ is released

potassium

intracellular fluid major cations (3)

potassium magnesium sodium

Cations (4 positive)

potassium K+ sodium Na+ calcium Ca 2+ magnesium Mg2+

Prophylactic eye treatment: prevents, in what situation is this most likely to be used

prevents opthalmia neonatorum in the case that the mother has gonorrhea. Erythromycin .5% ointment and tetracycline 1% also may be used.

caution with hypertonic solution

prolonged use can cause pulmonary edema cardiac renal.disease dehydration diabetic ketoacidosis administer slowly w infusion control pump

Dextrose solutions

provides calories, reduces catabolism of protein, offers fluid

caution for isotonic solution

pts with cardiac disease (FVE) excess fluid) pts with known/suspected ICP(intracranial pressure)

most body heat is lost as....

radient energy

Hyperphosphatemia causes

renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy

Nursing implementations in primary water deficit

replace fluid orally or IV with isotonic or hypotonic fluids

_______ is extremely painful for pt's with cold-injuries

rewarming

Isoosmolar weight

same weight proportion of particles (sodium etc ) and water

hypertonic solution used for

severe hyponatremia hypochloremia

when recoveing from heat stroke, you must prevent the pr from.....

shivering ----- bc when you shiver you start generating heat again

crystalloi uses

short term maintenance dehydration electrolyte imbalance

primary electrolyte in ECF, and keeps water in this compartment

sodium

extracellular fluid major cation (4)

sodium potassium calcium magnesium

Colloids

substances such as large protein molecules that do not readily dissolve into true solutions

containment

swaddling

as tissue starts to thaw, it starts to _______ so make sure to take off jewlery

swell

temp control LPI

temperature needs checked every 3-4 hours

frostbite pt's may develop _______ or _______ in recovery

tetanus, gangrene

Tonicity

the ability of a surrounding solution to cause a cell to gain or lose water

hydrostatic pressure

the force within a fluid compartment

active transport

the movement of materials through a cell membrane using energy

hemodialysis

the process by which waste products are filtered directly from the patient's blood - MAY BEEN SEEN IN HYPOTHERMIC PT'S BC OF DECREASED RENAL BLOOD FLOW

fluid and electrolyte balance

the process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes maintenance of the proper amounts and kinds of fluids and minerals in each compartment of the body

gavage feedings

these are slow feedings sent from the mouth to the nose into the stomach through a tube

transcellular fluid aka

third space

Primary protection against hypernaturemia is....

thirst

cold blood is thick and can act as a _______

thrombus - increasing MI, stroke, etc. risk

the addition of dextrose to N iv solution affects the ......

tonicity of solution

electrolyte functions

transmission and conduction of nerve impulse contraction of cardiac skeletal and smooth muscle normal kidney function change carbs to energy change amino acids to protein role in acid base balance regulate osmolality of cellular fluids

it is not unusual to place a ________ in heat stoke pt's

urinary catheters -or- ice lavage (to prevent blood clots) -or- rectal irrigation

how to monitor for Rhabomyolysis

urine color, amount, pH, and myoglobin + hydration

Tonicity

used primarily as measure of concentration of iv solutions compared w osmolality of body fluids

if hypertonic solution not diluted and given peripherally, risk is

vein irritation damage thrombosis

with a pt presents with severe hypothermia, the pt must be ______ before they can be declared dead

warmed to a temp of 86

hypertonic

when comparing two solutions, the solution with the greater concentration of solutes

Isotonic

when the concentration of two solutions is the same

Blood products

while.blood packed red blood cells plasma platelets

Phrophyl eye treat: When

within the first hour but is usually given at the later end of the hour to prevent distrupting the patients bonding time

wet conditions or contact with metal surfaces can make frost bike.....

worse

Subjective signs of impaired thermoregulation

• Thirst • Dizziness • Cramps • Personality change • Nausea, vomiting, or anorexia • Fatigue • Problem-based history: o Malignant hyperthermia o Environmental exposure o Recent injury

Populations at risk of thermoregulation issues:

• Very young (e.g., preterm newborns or small for gestational age [SGA] newborns) • Older adults • Homeless • Those who reside in very cold or hot climates • Males • Physiological impairment

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take? a. Remind the patient about the need to drink 1000 mL of fluids daily. b. Obtain a midstream urine specimen for culture and sensitivity testing. c. Teach the patient to take the prescribed Bactrim for at least 3 more days. d. Suggest that the patient use acetaminophen (Tylenol) to treat the symptoms.

ANS: B Since uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Tylenol would not be as effective as other over-the-counter (OTC) medications such as phenazopyridine (Pyridium) in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Since the UTI has persisted after treatment with Bactrim, the patient is likely to need a different antibiotic. DIF: Cognitive Level: Application REF: 1123-1125

Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first? a. Insert a straight catheter and drain the bladder. b. Assist the patient to take a 15-minute sitz bath. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.

ANS: B Sitz baths will relax the perineal muscles and promote voiding. Although the patient should be encouraged to drink fluids and Kegel exercises are helpful in the prevention of incontinence, these activities would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection (UTI) and should be avoided when possible DIF: Cognitive Level: Application REF: 1146

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

ANS: B Solution at body temperature is used for ear irrigation. The patient should be sitting for the procedure. Use of cotton-tipped applicators to clear the ear may result in forcing the cerumen deeper into the ear canal. The ear should not be completely occluded with the syringe

11. Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication will prevent infections that cause the diarrhea."

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

A patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Catheterization technique and schedule c. Analgesic use before emptying the pouch d. Use of barrier products for skin protection

ANS: B The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful. DIF: Cognitive Level: Application REF: 1155-1156

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patient's external ear for redness, swelling, or presence of skin lesions.

ANS: B The Snellen test does not require nursing judgment and is appropriate to delegate to UAP who have been trained to perform it. History taking about infection or medications and assessment are actions that require critical thinking and should be done by the RN.

The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? a. Apply antibiotic drops to the eye several times daily. b. Wash hands frequently and avoid touching the eyes. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

ANS: B The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful hand washing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids are immunosuppressive and typically are not ordered because they can contribute to a longer course of infection and more complications

36. A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

ANS: B The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

24. The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

ANS: B The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.

The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

ANS: B The lenses are prescribed to correct the patient's near and distant vision. The nurse may also assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data do not evaluate whether the patient's bifocals are effective

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective coping related to inability to admit the impact of the eye injury

ANS: B The loss of stereoscopic vision created by the eye patch impairs the patient's ability to see in three dimensions and to judge distances. It also increases the risk for falls. There is no evidence in the assessment data for ineffective health maintenance, disturbed body image, or ineffective denial.

Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? a. Morphine sulfate 4 mg IV b. Mannitol (Osmitrol) 100 mg IV c. Betaxolol (Betoptic) 1 drop in each eye d. Acetazolamide (Diamox) 250 mg orally

ANS: B The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol. The other medications are also appropriate for a patient with glaucoma but would not be the first medication administered

7. What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation? a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor

ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

2. A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about a. tympanometry. b. rotary chair testing. c. pure-tone audiometry. d. bone-conduction testing.

ANS: B The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function. The other tests are used to test for problems with hearing.

A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is most appropriate at this time? a. Grieving related to current loss of functional vision b. Anxiety related to the possibility of permanent vision loss c. Situational low self-esteem related to loss of visual function d. Risk for falls related to inability to see environmental hazards

ANS: B The patient's restlessness and questioning of the nurse indicate anxiety about the future possible loss of vision. Because the patient can see with the right eye, functional vision is relatively intact. There is no indication of impaired self-esteem at this time

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. readiness for enhanced coping related to need for information. d. self-care deficit, toileting, related to denial of altered body function.

ANS: B The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a concern for the patient. The patient does not appear to be ready for enhanced coping. The patient's insistence that only the ostomy nurse care for the stoma indicates that denial is not present. DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

ANS: B The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take

Which information will the nurse provide to the patient scheduled for refractometry? a. "You should not take any of your eye medicines before the examination." b. "You will need to wear sunglasses for a few hours after the examination." c. "The doctor will shine a bright light into your eye during the examination." d. "The surface of your eye will be numb while the doctor does the examination."

ANS: B The pupils are dilated using cycloplegic medications during refractometry. This effect will last several hours and cause photophobia. The other teaching would not be appropriate for a patient who was having refractometry.

The nurse is observing a student who is preparing to perform an ear examination for a 30-yr-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear up and posterior. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

ANS: B The speculum should be smaller than the ear canal so it can be inserted without damage to the external ear canal. The other actions are appropriate when performing an ear examination.

Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Evaluate a patient's ability to administer eye drops. b. Use a Snellen chart to check a patient's visual acuity. c. Teach a patient with otosclerosis about use of sodium fluoride and vitamin D. d. Check the patient's external ear for signs of irritation caused by a hearing aid.

ANS: B Using standardized screening tests such as a Snellen chart to test visual acuity is included in LPN education and scope of practice. Evaluation, assessment, and patient teaching are higher level skills that require RN education and scope of practice

16. An infant delivered preterm at 28 weeks' gestation weighs 1200 g. Based on this information, the infant is designated as: a. SGA. b. VLBW. c. ELBW. d. Low birth weight at term.

ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely-low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. However, this option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.

Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene immediately? a. UAP raise the side rails on the bed. b. UAP turn on the patient's television. c. UAP turn the patient to the right side. d. UAP place an emesis basin at the bedside.

ANS: B Watching television may exacerbate the symptoms of an acute attack of Ménière's disease. The other actions are appropriate because the patient will be at high fall risk and may suffer from nausea during the acute attack

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% c. Decreased peripheral edema b. Absence of skin tenting d. Blood pressure 110/72 mm Hg

ANS: C Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor c. Mental status b. Heart sounds d. Capillary refill

ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K + 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4 -3 4.8 mg/dL (1.55 mmol/L)

ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give prescribed PRN morphine sulfate IV.

ANS: C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

ANS: C The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1°F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) over the admission weight

ANS: C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a. Deficient fluid volume c. Risk for injury: seizures b. Impaired gas exchange d. Risk for impaired skin integrity

ANS: C The patient's muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.

19. The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? a. Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. b. The patient will begin sitting in a chair at the bedside on the first postoperative day. c. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.

ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

4. A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to a. irrigate the eyes with saline solution. b. apply cool compresses to the eyes three times daily. c. use a gentle baby shampoo to clean the lids as needed. d. schedule an appointment for surgical removal of the lesion.

ANS: C Baby shampoo is used to soften and remove crusts associated with blepharitis. The other interventions are not used in treating this disorder.

1. Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

21. A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

A patient undergoes a nephrectomy after having massive trauma to the kidney. Which assessment finding obtained postoperatively is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Incisional pain level is 8/10. c. Urine output is 20 mL/hr for 2 hours. d. Crackles are heard at both lung bases.

ANS: C Because the urine output should be at least 0.5 mL/kg/hr, a 40 mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain. DIF: Cognitive Level: Application REF: 1154-1155

29. A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

Which assessment finding alerts the nurse to provide patient teaching about cataract development? a. History of hyperthyroidism b. Unequal pupil size and shape c. Blurred vision and light sensitivity d. Loss of peripheral vision in both eyes

ANS: C Classic signs of cataracts include blurred vision and light sensitivity. Thyroid problems are a major cause of exophthalmos. Unequal pupil is not indicative of cataracts. Loss of peripheral vision is a sign of glaucoma.

A patient who has undergone a left tympanoplasty should be instructed to a. remain on bed rest. b. keep the head elevated. c. avoid blowing the nose. d. irrigate the left ear canal.

ANS: C Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation

40. Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

13. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider? a. Dysuria b. Hematuria c. Left-sided flank pain d. Temperature 100.1° F

ANS: C Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection (UTI). DIF: Cognitive Level: Application REF: 1132-1133

14. Which statement is most true about large-for-gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

12. What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a. All body parts appear proportionate. b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body. d. One side of the body appears slightly smaller than the other.

ANS: C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin because of lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected because of the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

5. Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths/min d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: C Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time.

18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy

ANS: C Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.

A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? a. "I will apply the eardrops to the cotton wick in the ear canal." b. "I can use aspirin or acetaminophen (Tylenol) for pain relief." c. "I will clean the ear canal daily with a cotton-tipped applicator." d. "I can use warm compresses to the outside of the ear for comfort."

ANS: C Insertion of instruments such as cotton-tipped applicators into the ear should be avoided. The other patient statements indicate that the teaching has been successful

The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to a. obtain more information about the cause of the patient's vision loss. b. obtain information from the spouse about the patient's special needs. c. make eye contact with the patient and ask about any need for assistance. d. perform an evaluation of the patient's visual acuity using a Snellen chart.

ANS: C Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions. The patient (rather than the spouse) should be asked about any need for assistance. The information about the cause of the vision loss and assessment of the patient's visual acuity are not priorities during the initial assessment

The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time? a. The patient has had blurred vision for 3 years. b. The patient has not eaten anything for 8 hours. c. The patient takes 2 antihypertensive medications. d. The patient gets nauseated with general anesthesia.

ANS: C Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants and may increase heart rate and blood pressure. Using punctal occlusion when administering the mydriatic and monitoring of blood pressure are indicated for this patient. Blurred vision is an expected finding with cataracts. Patients are expected to be NPO for 6 to 8 hours before the surgical procedure. Cataract extraction and intraocular lens implantation are done using local anesthesia

The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? a. Atenolol taken to prevent angina b. Acetaminophen taken frequently for headaches c. Ibuprofen taken for 20 years to treat osteoarthritis d. Albuterol taken since early childhood to treat asthma

ANS: C Nonsteroidal antiinflammatory drugs are potentially ototoxic. Acetaminophen, atenolol, and albuterol are not associated with hearing loss.

Which action should the nurse take when providing patient teaching to a 76-yr-old patient with mild presbycusis? a. Use patient education handouts rather than discussion. b. Use a higher-pitched tone of voice to provide instructions. c. Ask for permission to turn off the television before teaching. d. Wait until family members have left before initiating teaching.

ANS: C Normal changes with aging make it more difficult for older patients to filter out unwanted sounds, so a quiet environment should be used for teaching. Loss of sensitivity for high-pitched tones is lost with presbycusis. Because the patient has mild presbycusis, the nurse should use both discussion and handouts. There is no need to wait until family members have left to provide patient teaching.

A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating a. milk and dairy products. b. legumes and dried fruits. c. organ meats and sardines. d. spinach, chocolate, and tea.

ANS: C Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones. DIF: Cognitive Level: Application REF: 1139

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)? a. Take the medication for at least 7 days. b. Use sunscreen while taking the Pyridium. c. The urine may turn a reddish-orange color. d. Use the Pyridium before sexual intercourse.

ANS: C Patients should be taught that Pyridium will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Taking Pyridium before intercourse will not be helpful in reducing the risk for UTI. Pyridium does not cause photosensitivity.

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is appropriate to obtain more information about possible hearing problems? a. "Do you grind your teeth at night?" b. "What time do you usually fall asleep?" c. "Have you noticed ringing in your ears?" d. "Are you ever dizzy when you are lying down?"

ANS: C Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears. The responses "Do you grind your teeth at night?" and "Are you ever dizzy when you are lying down?" would be used to obtain information about other ear problems, such as vestibular disorders and referred temporomandibular joint pain. The response "What time do you usually fall asleep?" would not be helpful in assessing problems with the patient's ears.

17. A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant: a. Is exhibiting signs of RDS. b. Requires tactile stimulation around the clock to ensure that apneic periods do not progress further. c. Is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit. d. Requires the use of CPAP to promote airway expansion.

ANS: C Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

6. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes

ANS: C Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

38. Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

10. Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is the only recognized cause of this condition.

ANS: C SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA infants.

Which finding by the nurse for a patient admitted with glomerulonephritis indicates that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. Peripheral and periorbital edema is resolved. d. The antistreptolysin-O (ASO) titer is decreased.

ANS: C Since edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Antibodies to streptococcus will persist after a streptococcal infection. Nitrites will be negative and the patient will not experience dysuria since the patient does not have a urinary tract infection. DIF: Cognitive Level: Application REF: 1131-1133

Which assessment finding for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the physician? a. Cloudy appearing urine b. Hypotonic bowel sounds c. Heart rate 102 beats/minute d. Continuous drainage from stoma

ANS: C Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal. DIF: Cognitive Level: Application REF: 1157 | 1159-1160 | 1158-1159

Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)? a. Teach the patient about use of medications to reduce symptoms. b. Place the patient in a dark, quiet room to avoid stimulating BPPV attacks. c. Teach the patient that canalith repositioning may be used to reduce dizziness. d. Speak slowly and in a low-pitch to ensure that the patient is able to hear instructions.

ANS: C The Epley maneuver is used to reposition "ear rocks" in BPPV. Medications and placement in a dark room may be used to treat Ménière's disease, but are not necessary for BPPV. There is no hearing loss with BPPV

A 26-year-old patient with a history of polycystic kidney disease is admitted to the surgical unit after having knee surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Infuse 5% dextrose in normal saline at 75 mL/hr. b. Order regular diet after patient is awake and alert. c. Give ketorolac (Toradol) 10 mg PO PRN for pain. d. Obtain blood urea nitrogen (BUN), creatinine, and electrolytes in 2 hours.

ANS: C The NSAIDs should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change. DIF: Cognitive Level: Application REF: 1142-1143

When assessing a patient's consensual pupil response, the nurse should a. have the patient cover one eye while facing the nurse. b. observe for a light reflection in the center of both pupils. c. shine a light into one eye and observe responses of both pupils. d. instruct the patient to follow a moving object using only the eyes.

ANS: C The consensual pupil response is tested by shining a light into one pupil and observing for both pupils to constrict. Observe the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, ask the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the center of both corneas as the patient faces the light source. To perform confrontation visual field testing, the patient faces the examiner and covers one eye and then counts the number of fingers that the examiner brings into the visual field. Instructing the patient to follow a moving object only with the eyes is testing for visual fields and extraocular movements.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

47. A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

39. A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Foul-smelling urine b. Complaint of flank pain c. Blood pressure 88/45 mm Hg d. Temperature 100.1° F (57.8° C)

ANS: C The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis. DIF: Cognitive Level: Application REF: 1126

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.

ANS: C The nurse should discuss the impact of amplified music on hearing with young adults and discourage listening to very amplified music, especially for prolonged periods. Tympanometry measures the ability of the eardrum to vibrate and would not help prevent future hearing loss. Although students are at risk for the influenza virus, being vaccinated does not help prevent future hearing loss. Otoscopic examinations are not necessary for all patients

A patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect to find related to this illness? a. Poor skin turgor b. High urine ketones c. Recent weight gain d. Low blood pressure

ANS: C The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. DIF: Cognitive Level: Comprehension REF: 1132-1134

When assessing a 30-year-old man who complains of a feeling of incomplete bladder emptying and a split, spraying urine stream, the nurse asks about a history of a. bladder infection. b. recent kidney trauma. c. gonococcal urethritis. d. benign prostatic hyperplasia.

ANS: C The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection. DIF: Cognitive Level: Application REF: 1141

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a. Deficient fluid volume b. Impaired gas exchange c. Risk for injury: seizures d. Risk for impaired skin integrity

49. A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is: a. Soft and supple skin. b. A hematocrit level of 55%. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

ANS: C This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant. PTS: 1 DIF: Cognitive Level: Understanding REF: 646 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

42. Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take? a. Suggest the patient arrange a ride to the clinic immediately. b. Ask about the presence of "floaters" in the patient's visual field. c. Remind the patient it may take months to restore vision after transplant. d. Teach the patient to continue using prescribed pupil-dilating medications.

ANS: C Vision may not be restored for up to a year after corneal transplant. Because the patient is not experiencing complications of the surgery, an emergency clinic visit is not needed. Because "floaters" are not associated with complications of corneal transplant, the nurse will not need to ask the patient about their presence. Corticosteroid drops, not mydriatic drops, are used after corneal transplant surgery

12. A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

3. The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates which assessment finding? a. Decreased respirations b. Low pulse rate c. Red, sweaty skin d. Slow capillary refill

ANS: C With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

ANS: D Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low- potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

ANS: D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis c. Respiratory acidosis b. Metabolic alkalosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed normal saline bolus and insulin.

ANS: D The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.

ANS: D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

To prevent the recurrence of renal calculi, the nurse teaches the patient to: a. use a filter to strain all urine. b. avoid dietary sources of calcium. c. drink diuretic fluids such as coffee. d. have 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

3. A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

27. A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.

17. A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

The nurse performing an eye examination will document normal findings for accommodation when a. shining a light into the patient's eye causes pupil constriction in the opposite eye. b. a blink reaction follows touching the patient's pupil with a piece of sterile cotton. c. covering one eye for 1 minute and noting pupil constriction as the cover is removed. d. the pupils constrict while fixating on an object being moved toward the patient's eyes.

ANS: D Accommodation is defined as the ability of the lens to adjust to various distances. The pupils constrict while fixating on an object that is being moved from far away to near the eyes. The other responses may also be elicited as part of the eye examination, but they do not indicate accommodation.

Which statement by the patient to the home health nurse indicates a need for more teaching about self-administering eardrops? a. "I will leave the ear wick in place while administering the drops." b. "I should lie down before and for 5 minutes after administering the drops." c. "I will hold the tip of the dropper above the ear while administering the drops." d. "I should keep the medication refrigerated until I am ready to administer the drops."

ANS: D Administration of cold eardrops can cause dizziness because of stimulation of the semicircular canals. The other patient actions are appropriate

The nurse in the eye clinic is examining a 67-yr-old patient who says, "I see small spots that move around in front of my eyes." Which action will the nurse take first? a. Immediately have the ophthalmologist evaluate the patient. b. Explain that spots and "floaters" are a normal part of aging. c. Warn the patient that these spots may indicate retinal damage. d. Use an ophthalmoscope to examine the posterior eye chambers.

ANS: D Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber. Although the ophthalmologist will examine the patient, the presence of spots or floaters in a 65-yr-old patient is not an emergency. The spots may indicate retinal damage, but the nurse should assess the eye further before discussing this with the patient.

28. Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk b. Whole wheat toast with butter c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.

9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n): a. Hematocrit level of 58%. b. RBC count of 5 million/L. c. WBC count of 15,000 cells/mm3. d. Blood glucose level of 25 mg/dL.

ANS: D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5 million/L.

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider? a. Blood in urine b. Left flank pain c. Left flank bruising d. Drop in urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy. DIF: Cognitive Level: Application REF: 1138-1139

ANS: D Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

20. To determine a preterm infant's readiness for nipple feeding, the nurse should assess the: a. Skin turgor. b. Bowel sounds. c. Current weight. d. Respiratory rate.

ANS: D Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding.

A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)? a. Suprapubic pain b. Bladder distention c. Foul-smelling urine d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI. DIF: Cognitive Level: Application REF: 1128

31. The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

A 62-year-old asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

ANS: D Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. DIF: Cognitive Level: Application REF: 1148

A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care? a. Apply absorbent incontinent pads. b. Restrict fluids after the evening meal. c. Insert an indwelling catheter until the symptoms have resolved. d. Assist the patient to the bathroom every 2 hours during the day.

ANS: D In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. DIF: Cognitive Level: Application REF: 1151-1152

13. Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infant's weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 97°, 96°, and 97° F.

ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

34. Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Correct use of the antifungal eyedrops natamycin (Natacyn) b. How to apply corticosteroid ophthalmic ointment to the eyes c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Importance of taking all of the ordered oral acyclovir (Zovirax)

ANS: D Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are usually contraindicated because they prolong the course of the infection. Herpes simplex I is viral, not parasitic, or fungal. Natamycin may be used for Acanthamoeba keratitis caused by a parasite. NSAIDs can be used to treat the pain associated with keratitis

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. nausea. b. flank pain. c. poor urine output. d. pain with urination.

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI. DIF: Cognitive Level: Application REF: 1123-1124

8. The nurse planning care for a patient with hypothermia should consider what similar exemplar? a. Heat exhaustion b. Heat stroke c. Infection d. Prematurity

ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

2. In comparison with the term infant, the preterm infant has: a. More subcutaneous fat. b. Well-developed flexor muscles. c. Few blood vessels visible through the skin. d. Greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more characteristic of a term infant.

The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question? a. Morphine sulfate 4 mg IV b. Diazepam (Valium) 5 mg IV c. Betaxolol (Betoptic) 0.25% eyedrops d. Scopolamine patch (Transderm Scop) 1.5 mg

ANS: D Scopolamine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure. The other medications are appropriate for this patient

2. A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about the temperature. What is the nurse's best response? a. Older people have a diminished ability to regulate body temperature because of active sweat glands. b. Older people have a diminished ability to regulate body temperature because of increased circulation. c. Older people have a diminished ability to regulate body temperature because of peripheral vasoconstriction. d. Older people have a diminished ability to regulate body temperature because of slower metabolic rates.

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

11. Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration. c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings.

ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Using an alcohol-based hand cleaner before performing catheter care d. Disconnecting the catheter from the drainage tube to obtain a specimen

ANS: D The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection (UTI). The other actions are appropriate and do not require any intervention. DIF: Cognitive Level: Application REF: 1152-1154

When obtaining a health history from a 49-yr-old patient, which patient statement is most important to communicate to the primary health care provider? a. "My eyes are dry now." b. "It is hard for me to see at night." c. "My vision is blurry when I read." d. "I can't see as far over to the side."

ANS: D The decrease in peripheral vision may indicate glaucoma, which is not a normal visual change associated with aging and requires rapid treatment. The other patient statements indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a normal part of aging.

4. What is the priority nursing action for a patient suspected to be hypothermic? a. Assess vital signs. b. Hydrate with intravenous (IV) fluids. c. Provide a warm blanket. d. Remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

Which action will the nurse include in the plan of care for a patient who has had a ureterolithotomy and has a left ureteral catheter and a urethral catheter in place? a. Provide education about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Clamp the ureteral catheter unless output from the urethral catheter stops. d. Call the health care provider if the ureteral catheter output drops suddenly.

ANS: D The health care provider should be notified if the ureteral catheter output decreases since obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided in order to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Since the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed. DIF: Cognitive Level: Application REF: 1153-1154

A 75-year-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? a. Discuss the increased risk for falls that is associated with impaired vision. b. Explain that there are many ways to compensate for decreases in visual acuity. c. Suggest ways of improving the patient's safety, such as using brighter lighting. d. Ask the patient more about what type of vision problems are being experienced.

ANS: D The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about a. premedicating to prevent nausea. b. where to obtain wigs and scarves. c. the importance of oral care during treatment. d. the need to empty the bladder before treatment.

ANS: D The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy. DIF: Cognitive Level: Application REF: 1146

44. Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

7. A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Encourage the patient to sip clear liquids. b. Assess the abdomen for rebound tenderness. c. Assist the patient to cough and deep breathe. d. Apply an ice pack to the right lower quadrant.

ANS: D The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

43. After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

In reviewing a 55-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess a. visual acuity. b. pupil reaction. c. color perception. d. peripheral vision.

ANS: D The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision. Because central visual acuity is unchanged by glaucoma, assessment of visual acuity could be normal even if the patient has worsening glaucoma. Color perception and pupil reaction to light are not affected by glaucoma

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

ANS: D The patient's sensation that a curtain is coming across the field of vision suggests retinal detachment and the need for rapid action to prevent blindness. The other findings would be expected with the patient's history of being hit in the eye

A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective? a. "I will need to use bright lights to read for at least the next week." b. "I will use drops to keep my pupils dilated until my appointment." c. "I will not use facial lotions near my eyes during the recovery period." d. "I will cover up with long-sleeved shirts and pants for the next 5 days."

ANS: D The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on the use of facial lotions, medications to keep the pupils dilated would not be appropriate, and bright lights would increase the risk for damage caused by the treatment

37. A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.

ANS: D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

22. A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200? a. How to access audio books b. How to use a white cane safely c. Where Braille instruction is available d. Where to obtain specialized magnifiers

ANS: D Various types of magnifiers can enhance the remaining vision enough to allow the performance of many tasks and activities of daily living (ADLs). Audio books, Braille instruction, and canes usually are reserved for patients with no functional vision

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. facing the patient directly when speaking. b. speaking slowly and distinctly to the patient. c. administering both the Rinne and Weber tests. d. encouraging the patient to ambulate independently.

ANS: D Vestibular disease affects balance, so the nurse should monitor the patient during activities that require balance. The other actions might be used for patients with hearing disorders.

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) for a patient with cystitis has been effective when the patient states, a. "I can use vaginal sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is dis- couraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

When assisting a blind patient in ambulating to the bathroom, the nurse should a. take the patient by the arm and lead the patient slowly to the bathroom. b. have the patient place a hand on the nurse's shoulder and guide the patient. c. stay beside the patient and describe any obstacles on the path to the bathroom. d. walk slightly ahead of the patient and allow the patient to hold the nurse's elbow.

ANS: D When using the sighted-guide technique, the nurse walks slightly in front and to the side of the patient and has the patient hold the nurse's elbow. The other techniques are not as safe in assisting a blind patient

ECF volume deficit (hypovolemia)

Abnormal loss of body fluids, inadequate fluid intake, or plasma to interstitial fluid shift

A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case?

Administer the prescribed antipyretic and notify the primary health care provider of this change.

late preterm infant

An infant born between 34 0/7 and 36 6/7 weeks of gestation.

A pediatric client with a past history of chicken pox reports a fever and headache. Which medication would the nurse avoid giving to the client?

Aspirin

Which antipyretic medication may cause Reye syndrome in children?

Aspirin

What must a patient with hypertension do to prevent or delay the onset of chronic kidney disease? Select all that apply. a. Drink at least 2 L of water daily. b. Adhere to drug and diet regimens. c. Test for microalbuminuria every year. d. Have blood and urine tests every 16 months. e. Take nonsteroidal anti-inflammatory drugs daily.

B,C b. Adhere to drug and diet regimens. c. Test for microalbuminuria every year.

After reviewing the lab reports of a patient, the nurse administers an intravenous (IV) bolus of saline before administering IV ibuprofen. Which values did the nurse notice before this intervention? Select all that apply. a. Hemoglobin: 9 gm/dL b. Serum calcium: 7 mg/dL c. Serum creatinine: 2.5 mg/dL d. Blood pressure: 150/90 mm Hg e. Blood urea nitrogen: 35 mg/dL f. Fasting blood sugar: 120 mg/dL

B,C,E b. Serum calcium: 7 mg/dL c. Serum creatinine: 2.5 mg/dL e. Blood urea nitrogen: 35 mg/dL

A patient is prescribed subcutaneous synthetic erythropoietin. What does the nurse teach the patient about the drug? Select all that apply. a. Take stool softeners. b. Report breathing difficulty. c. Report any muscle weakness. d. Have hemoglobin levels monitored weekly. e. It is used to stimulate red blood cell growth.

B,D,E b. Report breathing difficulty. d. Have hemoglobin levels monitored weekly. e. It is used to stimulate red blood cell growth.

BNP levels

BNP refers to "brain natriuretic peptide," a hormone that helps regulate the body's salt and water content, as well as blood pressure. In healthy people, BNP levels are usually below 100 pg/ml

patients at risk for hyperkalemia

Burn injury Crush injury Prolonged demyelination

When caring for a patient with a forearm arteriovenous (AV) fistula created for hemodialysis, which actions must the nurse take? Select all that apply. a. Check brachial pulses daily. b. Elevate the arm above heart level. c. Auscultate for a bruit every 8 hours. d. Teach the patient to palpate for a thrill over the site. e. Ensure that no blood pressure measurements are taken in that arm.

C,D,E c. Auscultate for a bruit every 8 hours. d. Teach the patient to palpate for a thrill over the site. e. Ensure that no blood pressure measurements are taken in that arm.

The nurse assists a patient with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply. a. Low fat b. Liberal sodium c. Low potassium d. Restricted fluids e. Restricted protein

C,D,E c. Low potassium d. Restricted fluids e. Restricted protein

A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? A. Tap water B. Sterile Water C. 0.9% Sodium Chloride D. 0.45% Sodium Chloride

C. 0.9% Sodium Chloride

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability

C. Areflexia

Active external rewarming

CONDUCTION -body to body contact -fluid or air filled warming blankets -warm water immersion

transcellular compartment

CSF, serous fluids (peritoneal, pleural, pericardial, synovial,ocular)

CM's of hypokalemia

Cardiac most serious Skeletal muscle weakness (legs) Weakness of respiratory muscles Decreased GI motility Hyperglycemia

apneic spells

Cessation of breathing for more than 20 seconds accompanied by cyanosis or bradycardia. -common in preterm infants

periodic breathing

Cessation of breathing lasting 5 to 10 seconds; may be followed by 10 to 15 seconds of rapid respirations without changes in color or heart rate.

Chvostek's sign

Cheek, facial spasm when Cheek is tapped associates with hypocalcemia

postmaturity syndrome

Condition in which a postterm infant shows characteristics indicative of poor placental functioning before birth. Also called dysmaturity syndrome.

afterdrop

Condition in which the body core temperature continues to decrease even after rewarming has begun.

Interprofessional Care for ECF volume imbalances

Correct the underlying cause and replace water and electrolytes • Orally • Blood products • Balanced IV solutions

A patient with acute kidney injury (AKI) is scheduled to undergo dialysis. What types of nutritional therapy may be required for the patient? Select all that apply. a. 40 g of protein per day b. Sodium intake up to 100 mEq c. Potassium intake up to 90 mEq d. Total parenteral nutrition (TPN) e. Fluid intake equal to urine output plus 500 mL

D,E d. Total parenteral nutrition (TPN) e. Fluid intake equal to urine output plus 500 mL

4 things to monitor when dealing with ECF fluid imbalances

Daily weights I & O Laboratory findings Cardiovascular care

While assessing a neonate's temperature, the nurse observes a drop in the body temperature. Which would be the reason for this temperature drop?

Decreased nonshivering thermogenesis

Osmosis

Diffusion of water through a selectively permeable membrane

two things that need to be considered when evaluating for systemic hypothermia

Does amputation need to happen? Does hospitalization need to occur?

Signs for hypoglycemia

Drop in temperature accompanied by respiratory distress may indicate low blood sugar levels as oxygen is instead used for non shivering thermogenesis. Shakeyness is also an indication HOWEVER hypoglycemia can be asymptomatic >:l

Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply. One, some, or all responses may be correct.

Dyspnea, Diaphoresis,High temperature

Hyperkalemia CMs are...

Dysrhythmias Fatigue, confusion Tetany, muscle cramps Weak or paralyzed skeletal muscles Abdominal cramping or diarrhea

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. Which type of heat loss would this intervention prevent?

Evaporation

Fluid volume excess (hypervolemia) def & CM's

Excess intake of fluids, abnormal retention of fluids, or interstitial-to-plasma fluid shift - Clinical manifestations related to excess volume • Weight gain is the most common

total body fluid is contained in either (2)

Extracellular fluid (ECF) Intracellular fluid (ICF)

Intervention for hypoglycemia

Feeding or if severe use IV. Glucose water is not recommended

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. One, some, or all responses may be correct.

Fingers, Ear lobes

ECF volume deficit nursing diagnoses

Fluid imbalance Impaired cardiac output Acute confusion Potential complication: Hypovolemic shock

chem formula for bicarbonate

HCO3-

hypotonic

Having a lower concentration of solute than another solution

Signs of difficult transition: immediately note the rate and character of

Heart rate, pulses, respirations and breath sounds.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105°F (40.6°C), orally. Which condition would the nurse suspect in the client?

Heat stroke

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. Which condition is the nurse trying to prevent in this client?

Heatstroke

Hypernatremia

High serum sodium may occur with inadequate water intake, excess water loss or sodium gain Causes hyperosmolality leading to cellular dehydration

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. Which part of the client's brain would the nurse suspect is injured?

Hypothalamus

Crystalloid solutions

IV fluids containing varying concentrations of electrolytes. can freely cross capillary walls

total parenteral nutrition

IV infusion of solutions containing the major nutrients needed for metabolism and growth

A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as a heat stroke?

Increased heart rate

Hypokalemia causes

Increased loss of K+ via the kidneys or gastrointestinal tract Increased shift of K+ from ECF to ICF Dietary K+ deficiency (rare) Renal losses from diuresis

Vitamin K synth

Infants cannot synth in the intestinces without normal flora, they are deficient in clotting factors.

barotrauma

Injury resulting from pressure disequilibrium across body surfaces; for example, from too much pressure in the lungs.

Categories of Thermoregulation

Intrinsic Metabolic Hormonal o Extrinsic Injury/trauma Environmental

D5W tonicity

Isotonic in bottle but becomes hypotonic in the body after dextrose is metabolized

Dehydration

Loss of pure water without corresponding loss of sodium

Hematocrit levels (low/normal/high)

Low- Male= <42. Female=<35 Normal- Male=42-54, Female= 35-46. High- Male=>54, Female=>46

The healthy range for hemoglobin is: For men, ______. For women, _____.

MEN: 13.2 to 16.6 grams per deciliter WOMEN: 11.6 to 15 grams per deciliter

Creatinine clearance is often measured as milliliters per minute (mL/min) or milliliters per second (mL/s). Normal values are: Male: ______. Female: _____

MEN: 97 to 137 mL/min (1.65 to 2.33 mL/s) WOMEN: 88 to 128 mL/min (1.496 to 2.18 mL/s).

RBC levels

Male: 4.7-6.1 million/mm3 Female: 4.2-5.4 million/mm3

Hemoglobin levels

Male= 13.2-17.3 g/dL Female= 11.7-16 g/dL

Clinical manifestations of hyponaturemia

Mild—headache, irritability, difficulty concentrating. More severe—confusion, vomiting, seizures, coma

Diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

NS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status.

The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature?

Neonate 3

Active internal rewarming

PUTTING WARM FLUIDS INDIDE BODY Warmed IV fluids Heated, humidified O2 Peritoneal lavage w/ warm fluids

Major intracellular cation

Potassium

Necrotizing enterocolitis

Pre-term infants have lower immune function, bacteria proliferate in bowel and cause ischemia and air in the bowel.

Interdisciplinary clinical management of thermoregulation issues; Primary

Prevention • Environmental control & shelter • Appropriate clothing • Physical activity • Exercise

Define thermoregulation

Processes that balance heat production and heat loss to maintain the body's temperature. Body surface temperature fluctuates according to external environment and is unreliable.Regulatory processes are measured in degrees and are best reflective true core temperature

Vit K function

Promotes Factor II (prothrombrin) VII, IX, and X

Passive external rewarming

RADIATION Move patient to warm, dry place; remove damp clothing; place warm blankets on patient ; use radient lights

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures. These episodes are longer than 24 hours. Which fever pattern would the nurse anticipate?

Relapsing

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this characteristic of?

Remittent

Treatment(s) for hypervolemia

Remove fluid without changing electrolyte composition or osmolality of ECF Diuretics Fluid restriction Restriction of sodium intake Removal of fluid to treat ascites or pleural effusion

Signs of difficult transition: Look for signs of

Respiratory distress, tachypnea, retractions, flaring of nares, pallor, or cyanosis, grunting, seesaw respirations, and asymmetry of chest movements

Potential complication of hypernaturemia

Seizures and coma

Which signs and symptoms are observed in the human body with a decrease in body temperature? Select all that apply. One, some, or all responses may be correct.

Shivering, Contraction of blood vessels

Vitamin K how much and when should it be admin

Should be given to neonate to prevent vit K deficiency bleeding. One dose intramusculary within the first hour of birth. Can be delayed until after breast feeding

ECHMO

Similar to cardio-pulmonary bypass used in OR Blood is taken outside body to be oxygenated, warmed, CO2 removed, and then pumped back to the body Veno-venous (vein to vein) Primarily for respiratory failure (ARDS) Veno-arterial (vein to artery) Primarily cardiac failure with respiratory support "A COMPLETE CARDIO-PULMONARY BYPASS" - allows the lungs and heart to rest/heal

Major ECF cation

Sodium

Electrolytes List

Sodium Potasium Chloride Bicarbonate Calcium Magnesium

hypertonic solution

Solute concentration is greater than that inside the cell; cell loses water

hypotonic solution

Solute concentration is less than that inside the cell; cell gains water

Fluid from lungs

Suctioned by mouth, by nose only if absolutely nessesary

volutrauma

The VOLUME of the air is more than the lungs can handle and physical damage to the lungs occurs.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concludes that the client's fever pattern is remittent. Which assessment finding led to this conclusion?

The client's fever spikes and falls without a return to normal temperature levels.

Hypernatremia Manifestations

Thirst Changes in mental status, ranging from drowsiness, restlessness, confusion and lethargy to seizures and coma Symptoms of fluid volume deficit

kangaroo care

Treatment for preterm infants that involves skin-to-skin contact.

Interdisciplinary clinical management of thermoregulation issues; Tertiary

Treatment!! • Hyperthermia o Identify underlying cause o Minimize cardiovascular and neurologic complications o Maintain or improve hydration o Provide cooling methods o Administer medications as needed Antipyretics Aspirin in adults Dantrolene sodium -----or----- • Hypothermia o Remove from wet/cold environment o Provide passive and/or active rewarming methods

Diuretic phase of AKI

UO 4000-5000 ml /day Increased BUN Loss of Na and K in urine Increased mental and physical activity

Oliguric phase of AKI

UO less than .5 ml/kg/hr N&V Increased Serum K, BUN, and creatinine Increased Ca, Na Decreased PH Anemia Pulmonary edema, CHF Hypertension Albuminuria

Expanded temp assessment

When newborn has low temp: check blood glucose, if low -> breast milk. Low temp is indication of possible infection

Tempp interventions

Women's abdomen, radiant warmer (no cap), dry, dry clothes, breast milk, warm water over hands before touoching, incubator or crib away from walls or windows if weather is cold, decrease drafts, don't expose body

Which causative agent is common to both hyperthermia and hypothermia? a) Alcohol b) Barbiturates c) Phenothiazines d) Cardiovascular disease

a) Alcohol - Alcohol is the causative agent that is common to both hyperthermia and hypothermia. Barbiturates and phenothiazines can cause hypothermia. Cardiovascular disease can cause hyperthermia.

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock? a) Cold, clammy skin b) Slow, bounding pulse c) Increased blood pressure d) Hyperactive bowel sounds

a) Cold, clammy skin - In cardiogenic shock, the action of the sympathetic nervous system causes vasoconstriction, which causes the skin to be cold and clammy. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs. Because of poor cardiac contractility, pulse quality is weak. Blood pressure decreases because of poor cardiac output. Hypoperfusion leads to hypoactive or absent bowel sounds.

A client with hypothermia is brought to the emergency department. Which treatment would the nurse anticipate? a) Core rewarming with warm fluids b) Ambulation to increase metabolism c) Frequent oral temperature assessments d) Gastric tube feedings to increase fluid volume

a) Core rewarming with warm fluids - Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. a) Oliguria b) Bradypnea c) Diaphoresis d) Tachycardia e) Hypertension

a) Oliguria c) Diaphoresis d) Tachycardia - Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.

While performing cardiac surgery, the cardiologist intentionally induces hypothermia in the client. Which rationale explains this intervention by the cardiologist? a) To prevent tissue ischemia b) To enhance anesthetic action c) To prevent blood loss during surgery d) To complete the surgery in a short time

a) To prevent tissue ischemia - Sometimes, surgeons intentionally induce hypothermia to decrease the oxygen requirement of the tissues and ultimately prevent tissue ischemia. The alteration of body temperature may not enhance the anesthetic action during surgery. Reduced body temperature is unrelated to blood clotting and may not prevent blood loss during surgery. Induced hypothermia is unrelated to the duration of surgery.

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. One, some, or all responses may be correct. a) Vasodilation b) Dry and flushed skin c) Pale and cyanotic skin d) Decreased capillary refill e) Decreased urinary output

a) Vasodilation b) Dry and flushed skin e) Decreased urinary output - During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result, the skin may be warm to the touch. Hyperthermia causes loss of water from the body and results in dry skin and mucous membranes, decreased urinary output, and other signs of dehydration and electrolyte imbalance. Clients with hyperthermia may not have pale and cyanotic skin; instead, they have dry, flushed skin. Clients with hyperthermia may not have decreased capillary refill; instead, they have increased capillary refill.

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock? a) oliguria b) crackles c) dyspnea d) bounding pulse

a) oliguria - Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema caused by cardiogenic shock, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, and also with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

The registered nurse teaches a student nurse about the dialysis catheter. Which statement of the student nurse indicates the need for further teaching? a. "Central venous pressure is measured from the catheter." b. "The catheter should be placed in the internal jugular vein." c. "The catheter should not be used to acquire blood sample." d. "Informed consent should be obtained from the patient before placing the catheter."

a. "Central venous pressure is measured from the catheter.

The registered nurse teaches a student nurse about tubular damage in the kidneys. Which statement by the student nurse indicates the need for further teaching? a. "Tubular damage results in intrarenal acute kidney injury." b. "Tubular damage is caused by immune-mediated complexes." c. "In mild tubular damage, the nephrons will retain the ability to repair." d. "Urinalysis shows the presence of tubular debris and sediments."

a. "Tubular damage results in intrarenal acute kidney injury."

A patient awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? a. "You sound frustrated with the situation." b. "You're right; the wait is endless for some people." c. "I'm sure you'll get a phone call as soon as a kidney is available." d. "I'll talk to the health care provider and have your name removed from the waiting list."

a. "You sound frustrated with the situation."

Which instruction does the nurse provide to a patient with hypertension and diabetes to prevent or delay the onset of chronic kidney disease (CKD)? a. Adhere to all drug and diet regimens. b. Test for microalbuminuria every 6 months. c. Take over-the-counter drugs after checking labels. d. Take over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) if required.

a. Adhere to all drug and diet regimens.

What does the nurse identify as a possible cause of postrenal acute kidney injury (AKI) in a patient? a. Bladder cancer b. Acute tubular necrosis c. Pulmonary embolism d. Exposure to nephrotoxins

a. Bladder cancer

The nurse provides care for a patient with severe dehydration. Which laboratory value is the most critical for the nurse to monitor to prevent acute kidney injury (AKI)? a. Creatinine b. Serum sodium c. Serum potassium d. Blood urea nitrogen

a. Creatinine

Arrange the changes of the kidney during chronic kidney disease in order of occurrence. a. Destruction of nephrons b. Fluid overload c. Production of urine with fixed osmolarity d. Decreased ability to produce diluted urine e. Pressure on healthy nephrons, to maintain homeostasis f. Increased blood urea nitrogen and decreased urine output

a. Destruction of nephrons e. Pressure on healthy nephrons, to maintain homeostasis d. Decreased ability to produce diluted urine c. Production of urine with fixed osmolarity f. Increased blood urea nitrogen and decreased urine output b. Fluid overload

While assessing a patient suffering from acute kidney injury, the nurse observes peripheral edema and declined cognition. Further laboratory reports reveal the findings given in the patient chart. What is the most appropriate treatment? a. Dialysis b. Low-potassium diet c. Administration of diuretics d.Intravenous saline infusion

a. Dialysis

A patient with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the patient has not adhered to this restriction? a. Dyspnea and anxiety at rest b. Blood pressure of 118/78 mm Hg c. Weight loss of 3 lb during hospitalization d. Central venous pressure (CVP) of 6 mm Hg

a. Dyspnea and anxiety at rest

A patient is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? a. Handwashing b. Adherence to therapy c. Strict clean technique d. Monitoring for low-grade fever

a. Handwashing

Which assessment finding represents a positive response to erythropoietin therapy? a. Less fatigue b. Hematocrit of 26.7% c. Potassium within normal range d. Absence of spontaneous fractures

a. Less fatigue

What preventive measures should be taken while harvesting a kidney from a cadaveric patient? a. Maintaining perfusion by mechanical ventilation b. Surgical excision and storage in cool, sterile water c. Infusion of cool preservative solution in the abdominal aorta d. Removal of the kidney and storage in a cool electrolyte medium

a. Maintaining perfusion by mechanical ventilation

The nurse is teaching the family of a patient with chronic kidney disease how to manage fluid volume. What does the nurse teach the family? a. Monitor the patient for headache or blurred vision. b. Monitor for decreased blood pressure every 4 hours. c. Check for distended neck veins in the supine position. d. Weigh the patient weekly, on the same day and at the same time.

a. Monitor the patient for headache or blurred vision.

The blood pressure of four hypotensive patients is given below. Which patient is at risk of developing an acute kidney injury because of renal hypoperfusion? a. Patient A b. Patient B c. Patient C d. Patient D

a. Patient A

The RN has just received a change-of-shift report. Which of the assigned patients should be assessed first? a. Patient with chronic kidney failure who was just admitted with shortness of breath b. Patient with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted c. Patient with azotemia whose blood urea nitrogen and creatinine are increasing d. Patient receiving peritoneal dialysis who needs help changing the dialysate bag

a. Patient with chronic kidney failure who was just admitted with shortness of breath

Three hours after renal transplantation surgery, the patient complains of severe pain at the transplant site. Upon examination, blood pressure is 170/90 mm Hg and body temperature is 104°F. What should the nurse do for the immediate treatment of the patient? a. Prepare the patient for surgery b. Arrange for dialysis for the patient c. Administer the prescribed pain medication d. Request higher dosages for the prescribed immunosuppressive drugs

a. Prepare the patient for surgery

Which pathology may result in acute kidney injury (AKI) from a prerenal etiology? a. Reduced perfusion b. Damage to kidney tissue c. Obstruction of urine flow d. Chronic kidney disease

a. Reduced perfusion

The nurse places a long-term dialysis catheter into the internal jugular vein of a patient by making a 7 cm long subcutaneous tunnel. Why did the nurse use the tunneling technique? a. To reduce the risk of infection b. To secure the catheter in place c. To administer intravenous drugs d. To prevent blockage of the catheter

a. To reduce the risk of infection

A patient with severe azotemia reports severe chest pain radiating to the trapezoid region and difficulty in breathing. Upon examination, tachycardia, dysrhythmia, narrow pulse pressure, and low-grade fever are noticed. Which diagnosis is the nurse most likely to expect for this patient? a. Uremic pericarditis b. Infective pericarditis c. Idiopathic pericarditis d. Post-infarct pericarditis

a. Uremic pericarditis

*6. A patient is admitted to the hospital with severe renal colic. The nurse's first priority in management of the patient is to* a. administer opioids as prescribed. b. obtain supplies for straining all urine c. encourage fluid intake of 3-4L/day d. keep the patient NPO in preparation for surgery

a. administer opioids as prescribed.

*4.One of the nruse's most important roles in relation to acute poststreptococcal golmerulonephritis is to* a. promote early diagnosis and treatment of sore throats and skin lesions b.encourage patients to obtain antibiotic therapy for upper respiratory tract infections c.teach patients with APSGN that long term prophylactic antibiotic therapy is necessary to prevent recurrence d.monitor patients for respiratory symptoms that indicate the disease is affecting the alveolar basement membrane

a. promote early diagnosis and treatment of sore throats and skin lesions

*9. In planning nursing interventions to increase bladder control in the patient with urinary incontinence, the nurse includes:* a. teaching the patient to use Kegel exercises b.clamping and releasing a catheter to increase bladder tone c.teaching the patient biofeedback mechanisms to suppress the urge to void d.counseling the patient concerning choices of incontinence containment devices

a. teaching the patient to use Kegel exercises

ascites

abnormal accumulation of fluid in the abdomen

Temperature assessed every

according to agency policy, every half hour, until it is stable for 2 hours, then checked Q4hr, then Q8 and 12

_______ is a continued decrease in core body temperature after the victim is removed from the cold environment

after drop

death in heat stroke is related to...

amt of time in heat stroke

Preterm infant

an infant born before the beginning of the 38th week

Anion

an ion with a negative charge

Ringer's Solution

an isotonic salt solution frequently used in in vitro experiments designed to extend the life of isolated tissues removed from the body

2 principals of homeostasis/fluid and electrolyte balance

anions/cations must be balanced in each dept & remain electrically neutral fluid compartments remain is osmotic equilibrium except for transient changes

Hep function assessment

assess for signs of: Hypoglycemia by doing a blood screen

When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? a) An irreversible phenomenon b) A failure of the circulatory pump c) Usually a fleeting reaction to tissue injury d) Generally caused by decreased blood volume

b) A failure of the circulatory pump - In cardiogenic shock, ineffective cardiac pumping or contraction is the cause of the poor peripheral circulation. In the early stages, cardiogenic shock is reversible. Cardiogenic shock indicates a severe and usually chronic decrease in cardiac function and is not a fleeting reaction to tissue injury (such as might occur with anaphylactic shock). Cardiogenic shock is caused by poor cardiac function and results in hypervolemia. A decrease in blood volume would cause hypovolemic shock.

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