373 EAQ
After reviewing the chart for a client who was recently admitted to the emergency department, which intervention will the nurse anticipate implementing immediately? Admission notes No known allergies No chronic health problems Involved in a motor vehicle collision X-ray confirms compound fracture of the right femur Physical assessment Breath sounds clear on auscultation Confused, restless, and groaning Neuro vascular assess of affected leg reveals symmetrical pedal pulses, movement of toes in response to touch, skin color equal to unaffected leg Vital signs Temp 99f Pulse: 120 regular rhythm RR: 30 BP: 92/50
Intravenous fluids The client probably is experiencing hypovolemic shock, as evidenced by the vital signs (elevated pulse and respirations and low blood pressure). Intravenous fluids will help correct the hypovolemia. Analgesics should not be administered until after the client is assessed fully, particularly for a head injury. Antibiotics may be prescribed eventually, but this is not the initial intervention. Packed red blood cells eventually may be administered, but this depends on an additional physical assessment and hematologic laboratory tests.
Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? Complete blood count Serum potassium level Arterial blood gas panel Urine osmolarity
Serum potassium level Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit
Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? Sodium Calcium Potassium Magnesium
Sodium Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.
When evaluating for response to treatment for a client with pharyngitis, which action will the nurse take? 1 Use a nasal speculum to inspect the nasal turbinates. 2 Palpate over the forehead and cheeks for tenderness. 3 Use a tongue blade to inspect the tonsils for swelling. 4 Listen with the stethoscope over both posterior lungs.
3 Use a tongue blade to inspect the tonsils for swelling Pharyngitis is an inflammation of the throat and the nurse will inspect the tonsils for improvement in enlargement and exudates. A nasal speculum would be used to inspect the nares for a client with rhinitis. Improvement in a client with sinusitis is assessed by palpating over the sinuses for improvement in tenderness or warmth. Improvement in lower respiratory infections such as pneumonia is evaluated by auscultation of lung sounds.
Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. Diuretics Low salt diet Daily weigh check Fluid restriction Intake and output Oxygen administration
All of the above Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.
Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain All of the above
All ofthe above Rationale: Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.
Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon
3 Beta interferon Beta interferon is an immunomodulator administered in the treatment of multiple sclerosis. Interleukin 11 (IL-11) prevents development of thrombocytopenia after chemotherapy. IL-2 treats metastatic renal cell carcinoma and metastatic melanoma. Alpha interferon treats hairy cell leukemia, chronic myelogenous leukemia, and malignant melanoma
Which client's activity might have led to insertion of an epistaxis catheter to treat the posterior nasal bleeding and developing pneumonia? 1 Using nasal saline sprays 2 Using drugs such as aspirin 3 Blowing the nose vigorously 4 Applying excess petroleum jelly to the nares
4 Applying excess petroleum jelly to the nares The sparing application of petroleum jelly to the nares helps lubricate the area and provide comfort to the client. However, excess use may cause inhalation of the jelly into the lungs and may increase the risk of pneumonia. Nasal saline sprays are used to moisten the nares and prevent rebleeding. Medications such as aspirin should be avoided after the placement of an epistaxis catheter to prevent bleeding. Vigorous nose blowing does not cause pneumonia.
The nurse is performing an assessment of fine motor skills on an infant. Which actions would the nurse observe? Select all that apply. One, some, or all responses may be correct. 1 Crawling 2 Creeping 3 Sitting erect 4 Holding a rattle 5 Picking up objects 6 Holding a baby bottle
4,5,6 Holding a rattle, picking up objects, and holding a baby bottle are demonstrations of fine motor skills. Gross motor skills include crawling, creeping, and sitting erect.
The nurse is reviewing the laboratory reports of a group of older adult clients. Which client has an age-related impairment of the thirst mechanism? Serum sodium concentration A; 167 mEq/L B: 143 C: 118 D; 101
A Older adult clients are at greater risk of fluid and electrolyte imbalances such as dehydration and hypernatremia due to age-related impairment of the thirst mechanism. The normal serum sodium concentration is between 135 and 145 mEq/L. Client A has a serum sodium concentration of 167 mEq/L, which is higher than normal, thereby indicating hypernatremia. Client B has a serum sodium concentration of 143 mEq/L, which is a normal value. The serum sodium concentration of client C is 136 mEq/L, which is a normal value. Client D has a serum sodium concentration of 140 mEq/L, which is in the normal range.
When assessing a client who has lost a large amount of blood after an automobile collision, which finding would the nurse expect? Urine output of 50 mL/hr Blood pressure of 150/90 Apical heart rate of 142 RR of 16
Apical heart rate of 142 In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood flow to body organs. Urine output would fall to less than 30 mL/h, because a decreased blood volume causes a decreased glomerular filtration rate. The blood pressure would decrease because of the decreased blood volume. Respiratory rate of 16 breaths/minute is within the accepted range of 12 to 20 breaths/minute; the respiratory rate is rapid with hypovolemic shock
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? Calcium Magnesium Bicarbonate Potassium chloride
Calcium These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.
Which finding by the nurse when assessing a client who is receiving intravenous (IV) fluids indicates need for a change in the fluid infusion rate? Crackles in lungs Supple skin turgor Urine output of 480 mL over 8 hr Heart rate decreased from 126 to 96
Crackles in the lungs Crackles in the lungs indicate the client is overloaded with fluids; the nurse would notify the health care provider and anticipate discontinuing or slowing the rate of the IV infusion. Supple skin turgor is a normal finding, indicating that the IV fluid is working. A urine output of 480 mL in 8 hours is adequate. A decrease in heart rate indicates improvement in hypovolemia
While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse's hand is used to perform this assessment? Fingertips Pads of fingertips Ulnar surface of hand Palmar surface of finger pads
Fingertips The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.
Which hormone regulates blood levels of calcium? Parathyroid hormone (PTH) Luteinizing hormone (LH) Hydroid stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH)
Parathyroid hormone (PTH) Parathyroid hormone (PTH) regulates the blood levels of calcium and phosphorus. LH stimulates the production of sex hormones, promotes the growth of reproductive organs, and also stimulates reproductive processes. TSH stimulates the release of thyroid hormones and the growth and functioning of the thyroid gland. ACTH promotes the growth of the adrenal cortex and stimulates the release of corticosteroids
Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? Rapid, thready pulse Intended jugular veins Elevated hematocrit level Increased serum sodium level
Distended jugular vein Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.
Which potential clinical manifestations would the nurse associate with a client diagnosed with systemic lupus erythematosus (SLE)? Select all that apply. One, some, or all responses may be correct. 1 Joint pain 2 Facial rash 3 Pericarditis 4 Weight gain 5 Hypotension
1 Joint pain 2 Facial rash 3 Pericarditis SLE is a chronic autoimmune disease that affects connective tissue; joint pain is common. A butterfly rash on the face is characteristic of SLE. Pericarditis is the most common cardiac indicator of SLE. Weight loss, not gain, is a classic sign of SLE because of gastrointestinal effects. Renal impairment with SLE may cause hypertension, not hypotension
On which body system would the nurse focus when assessing a client with suspected Goodpasture syndrome? 1 Renal 2 Neurological 3 Cardiovascular 4 Musculoskeletal
1 Renal Goodpasture syndrome is an autoimmune disorder in which autoantibodies attack the glomerular basement membrane and neutrophils. The organs with the most damage are the kidneys. A person with the disorder may have kidney problems, which manifest as glomerulonephritis that may rapidly progress to complete kidney failure. Goodpasture syndrome does not affect the neurological, cardiovascular, or musculoskeletal systems
Which gross motor skill would be observed in children between 8 and 10 months old? 1 The child can creep on his or her hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. 4 The child can bear his or her weight on forearms when prone.
1 The child can creep on his or her hands and. Knees A child between 8 and 10 months old can creep on his or her hands and knees. A child between birth and 1 month old has predominant inborn reflexes. A child between 6 and 8 months old can sit alone without support. A child between 2 and 4 months old can bear his or her weight on his or her forearms when in the prone position.
Which renal complication is likely to cause a client to experience anorexia, itching, nausea, vomiting, and muscle cramps? 1 Uremia 2 Nephritis 3 Nephrosis 4 Renal coilc
1 Uremia Uremia is a condition caused by a buildup of nitrogenous waste products due to kidney impairment. It is characterized by anorexia, itching, nausea, vomiting, and muscle cramps. Nephritis is characterized by kidney inflammation. Nephrosis is a degenerative process in the kidney. Renal colic is characterized by pain that radiates into the groin, scrotum or labia, and perineal area
After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral? 1 Potassium 2 Calcium 3 Magnesium 4 Sodium
2 Calcium The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroid glands; calcium gluconate is administered to treat hypocalcemia. Deficits in potassium, magnesium, and sodium do not cause these classic manifestations.
Which condition would the nurse monitor for in the client on aminoglycoside therapy and skeletal muscle relaxants? 1 Stroke 2 Respiratory arrest 3 Myocardial infarction 4 abdominal discomfort
2 Respiratory arrest Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for respiratory arrest. Aminoglycoside therapy with muscle relaxants does not increase the risk of stroke, myocardial infarction, or abdominal discomfort.
Which would the nurse use to perform hand hygiene when caring for an immunocompromised client 1 Soap 2 Betadine 3 Chlorhexidine 4 Alcohol-based hand sanitizer
3 Chlorhexidine Chlorhexidine will be used for hand hygiene when caring for immunocompromised clients because it decreases the risk of spreading infection. Cleansing hands with soap and alcohol-based hand sanitizers is not as effective at preventing the spread of infection. Betadine is not used for hand hygiene.
Which education would the nurse provide the parent of a 4-year-old child? 1 They are easy to please with food. 2 They master the ability to draw diamond shapes. 3 They double their birth length at this age. 4 They have an average weight of 32 pounds (14.51 kg).
3 They double their birth length at this age By around the age of 4 years, preschoolers have doubled their birth length. At this age, preschoolers develop finicky eating habits and are not easy to please with food. Drawing triangles and diamonds is usually mastered between the ages of 5 and 6 years. The average weight of preschoolers at the age of 4 years is 37 pounds (16.78 kg). Three-year-old children have an average weight of 32 pounds (14.51 kg).
Which is an inborn error of metabolism that affects growth and development? 1 Cystic fibrosis 2 Achondroplasia 3 Turner syndrome 4 Hunter syndrome
4 Hunter syndrome Hunter syndrome is an inborn error of metabolism that hinders development and results in altered physical appearance and impaired mental development. Cystic fibrosis is a genetic disorder that results in accumulation of mucus in the lungs and pancreas. Achondroplasia is a congenital disorder that is a common cause for the structural defect called dwarfism. Turner syndrome is a chromosomal abnormality associated with webbed neck and low-set ears.
Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? 1 Encourage frequent coughing 2 Elevate the client's lower extremities 3 Prepare for modified postural drainage 4 Place the client in the orthopneic position
4 Place the client in the orthopneic position The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Coughing is useful for clients who have excessive mucus in the airways, such as clients with pneumonia, but is not useful for clearing pulmonary edema. Elevation of the extremities should be prevented because it increases venous return, placing an increased workload on the heart. Positioning for postural drainage does not relieve acute dyspnea; furthermore, it increases venous return to the heart.
Which vitamin supplement should be given to the 1-month-old exclusively breast-fed infant? 1 Vitamin A 2 Vitamin B 3 Vitamin C 4 Vitamin D
4 Vitamin D Exclusively breast-fed infants are at risk for vitamin D deficiency. The American Academy of Pediatrics recommends that exclusively breast-fed infants take 400 IU of vitamin D beginning shortly after birth. Breast-fed infants do not require other vitamin supplements, including vitamins A, B, and C.
A registered nurse (RN) is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? "Edema results in the separation of kin from pigmented and vascular tissue" "Pitting edema leaves an indentation on the site of application of pressure" "Trauma or impaired venous return should be suspected in clients with edema" "If the pressure on n edematous site leaves an indentation of 2 mm, a score of 2+ is given"
"If the pressure of an edematous site leaves an indentation of 2 mm, 2+ is given" The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site leaves an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.
A client with end-stage renal disease has a mature arteriovenous (AV) fistula. Which interventions would the nurse include in the client's plan of care? Select all that apply. One, some, or all responses may be correct. 1 Auscultate the fistula for the presence of a bruit. 2 Palpate the site to identify the presence of a thrill. 3 Irrigate the fistula with saline to maintain patency. 4 Avoid drawing blood from the affected extremity. 5 Keep the fistula clamped until ready to perform dialysis.
1 Auscultate the fistula for the presence of abrupt 2 Palpate the site to identify the presence of a thrill 4 Avoid drawing blood from the affected extremity The presence of a bruit indicates patency of the AV fistula. The presence of a vibration or thrill indicates patency of the AV fistula. Avoid drawing blood from the extremity with the fistula to prevent damage to the AV fistula. An AV fistula is internal and is not irrigated. The AV fistula is under the skin and is not clamped.
The nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary health care provider prescriptions would the nurse do first? 1 Draw peripheral blood cultures from 2 different sites 2 Administer Levofloxacin 500 mg intravenously over 30 min 3 Administer 1 L intravenous bold of Ringer's lactate over 30 min 4 Take the client to x-ray for an abdominal computed tomography (CT) scan
1 Draw peripheral blood cultures from two different sites This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so that the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.
Which action would the nurse include in the plan of care for a client with ascites who is scheduled to have a paracentesis? 1 Instruct the client to urinate before the procedure. 2 Shave hair around and 2 to 3 inches (5-7.5 cm) beyond the puncture site. 3 Position the client on the side with the hips and knees flexed. 4 Measure the abdominal girth two fingerbreadths below the umbilicus.
1 Instruct the client to urinate before the procedure The bladder should be empty to prevent injury during insertion of the trocar. Shaving the hair from the needle insertion site is not necessary. Positioning a client on the side with the hips and knees flexed generally is the position assumed by the client for a spinal tap, not paracentesis; the upright position is assumed for a paracentesis to allow accumulation of fluid in the lower abdomen by gravity. Although regular monitoring of girth is important, it is not necessary before this procedure; abdominal girth is measured at the level of the umbilicus.
Which medications inhibit purine synthesis and suppress cell-mediated and humoral immune responses? Select all that apply. One, some, or all responses may be correct. 1 Sirolimus 2 Azathioprine 3 Cyclophosphamide 4 Methylprednisolone 5 Mycophenolate mofetil
2 Azathioprine 5 Mycophenolate mofetil Azathioprine and mycophenolate mofetil are administered to inhibit purine synthesis and suppress cell-mediated and humoral immunity. Sirolimus binds to a mammalian target of rapamycin (mTOR), which suppresses T-cell activation and proliferation. Cyclophosphamide is administered to treat cancers, autoimmune disorders, and amyloidosis. Methylprednisolone is a corticosteroid that inhibits cytokine production.
A client is receiving mechanical ventilation. When condensation collects in the ventilator tubing, which action would the nurse take? 1 Notify a respiratory therapist. 2 Drain the fluid from the tubing. 3 Decrease the amount of humidity. 4 Record the amount of fluid removed from the tubing.
2 Drain the fluid from the tubing Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid, and others have to be temporarily disconnected while the fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Humidity is necessary to preserve moistness of the respiratory tract and to help liquefy secretions. The amount of condensation is irrelevant when recording total intake and output.
Which developmental milestone would the nurse anticipate for a 15-month-old child? 1 Using a straw to drink 2 Drinking well from a cup 3 Chewing food with mouth closed 4 Spilling small amounts of food when using a spoon
2 Drinking well from a cup The nurse would anticipate that a 15-month-old toddler can drink well from a cup. The use of a straw to drink liquids and chewing food with the mouth closed is an expectation for the 24-month-old toddler. Spilling small amounts of food when using a spoon is an expectation for a 36-month-old toddler.
Which laboratory value will the nurse review to determine whether treatment for a client with a megaloblastic anemia has been successful? 1 Serum iron 2 Folate level 3 Transferin level 4 Reticulocyte count
2 Folate level Because folate and vitamin B12 deficiencies cause megaloblastic anemias, the nurse will review levels of those nutrients to determine whether treatment has been effective. Iron and transferrin levels will be used to evaluate treatment of iron deficiency anemia. Reticulocyte count may improve with successful treatment of any anemia, but is not as good an indicator as folate level for a client with a megaloblastic anemia.
Which parental statement would the nurse recognize as placing an infant at risk for injury? 1 "I feed my baby formula at room temperature." 2 "I heat the formula in the microwave for 30 seconds." 3 "I place the bottle of formula under hot water for 30 seconds." 4 "I set the bottle of formula in warm water for a few minutes."
2 I heat the formula in the microwave for 30 seconds Heating the formula in the microwave may cause oral burns due to the uneven heating in the container. Feeding the infant formula at room temperature, running the bottle under hot water for 30 seconds, or setting the bottle of formula in warm water for a few minutes does not place the infant at risk for injury.
The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action? 1 Assessing lung sounds every 15 minutes 2 Remaining with the client to assess responses 3 Monitoring the oxygen saturation levels frequently 4 Teaching the family members about ways to keep the client calm
2 Remaining with the client to assess responses This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress (e.g., shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, and tachypnea). Performing frequent lung sounds is important, but observation takes priority; it will allow the nurse to quickly identify signs of respiratory distress. Monitoring the saturation levels should be done more frequently, but direct observation is more important. Teaching family members to help with providing a calm environment is helpful but not the priority.
Which procedure would the nurse anticipate to confirm the diagnosis of Hirschsprung disease (congenital aganglionic megacolon) in a 1-month-old infant? 1 Colonoscopy 2 Rectal biopsy 3 Multiple saline enemas 4 Fiberoptic nasoenteric tube
2 Retail biopsy A full-thickness rectal biopsy involves the removal of some rectal tissue, which is examined microscopically for the absence of ganglion cells. A colonoscopy is not necessary to obtain a rectal biopsy specimen. A saline enema may relieve the obstruction, but it is not a definitive diagnostic tool; a barium enema may be used for diagnosis after the age of 2 months. A fiberoptic nasoenteric tube is not used to identify the cause of intestinal obstruction in infants.
Which test would the nurse monitor when determining whether a client's newly transplanted kidney works effectively? 1 Renal scan 2 Serum creatinine 3 24-hour urine output 4 White blood cell (WBC) count
2 Serum creatinine Serum creatinine, a test of renal function, measures the kidneys' ability to excrete metabolic wastes; creatinine, a nitrogenous product of protein breakdown, is elevated in renal insufficiency. A renal scan will not provide information about the filtering ability of the transplanted kidney. Although the nurse monitors the client's intake and output, this information will not provide information about the ability of kidney to excrete metabolic wastes. The WBC count will not reflect functioning of a transplanted kidney
A client taking immunosuppressant medications after receiving an organ transplant has developed hypertension, nephrotoxicity, and gingival hyperplasia. Which medication may have caused these disorders? Select all that apply. One, some, or all responses may be correct. 1 Sirolimus 2 Tacrolimus 3 Basiliximab 4 Cyclosporine 5 Mycophenolate
2 Tacrolimus 4 Cyclosporine Tacrolimus and cyclosporine are calcineurin inhibitors that may cause adverse effects such as hypertension, nephrotoxicity, and gingival hyperplasia. These medications are administered to stop the production and secretion of interleukin, which then prevents the activation of lymphocytes involved in transplant rejection. Basiliximab targets the activation sites of T-lymphocytes, increasing their elimination from circulation. Sirolimus is an antiproliferative medication that may cause adverse immunosuppressive effects such as thrombocytopenia and leucopenia. Basiliximab is a monoclonal antibody that may cause adverse side effects related to the gastrointestinal system. Mycophenolate may cause adverse effects such as leukopenia, thrombocytopenia, and nausea.
The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding? 1 Multi focal 2 Unifocal 3 Bigeminal 4 Couplet
2 Unifocal A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.
Which process would the IgD immunoglobulin found in human cord blood support? 1 Manifestation of allergic reactions 2 Protection of the body's mucous surfaces 3 Differentiation of B-lymphocytes 4 Provision of the primary immune response
3 Differentiation of B-lymphocytes IgD is present on the lymphocyte surface and found in human cord blood; this immunoglobulin differentiates B-lymphocytes. IgE causes symptoms of allergic reactions by adhering to mast cells and basophils. IgE also helps defend the body against parasitic infections. IgA lines the mucous membranes and protects body surfaces. IgM provides the primary immune response.
After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. The nurse concludes that which condition is the most likely cause of the pleural effusion? 1 Excessive fluid intake 2 Inadequate chest expansion 3 Extension of cancerous lesions 4 Irritation from the bronchoscopy
3 Extension of cancerous lesions Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space.
When arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH, which factor is the likely cause of the laboratory result? 1 Ketoaicidosis 2 Irregular heartbeat 3 Lactic acid production 4 Sodium bicarbonate administration
3 Lactic acid production Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Sodium bicarbonate causes alkalosis, not acidosis.
A client is diagnosed with pleural effusion. Which assessment finding would the nurse expect to identify? 1 Moist crackles at the posterior of the lungs 2 Deviation of the trachea toward the involved side 3 Reduced or absent breath sounds at the base of the lung 4 Increased resonance with percussion of the involved area
3 Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area
The nurse provides discharge teaching for a client who had a transurethral vaporization of the prostate. Which statement by the client indicates successful learning? 1 I should sit for several hours throughout the day 2 I should attempt to void every 2 hours when i am awake 3 I should avoid vigorous exercises for at least 6 months after surgery 4 I should notify my primary health care provider if my urinary stream decreases
4 I should notify my primary health care provider if my urinary stream decreases The surgical procedure affects the urethral mucosa in the area of the prostate, and strictures may form with healing. The client should notify his or her primary health care provider if his or her urinary stream decreases. The client should ambulate; sitting for several hours at a time is contraindicated because sitting promotes venous stasis and thrombus formation. The client should void as the need arises; straining to urinate can cause pressure in the operative area, precipitating hemorrhage. Although the client should avoid vigorous exercise immediately after surgery and during the healing process, 6 months is too long for this restriction.
Which happens during the transition from infant hood to toddlerhood 1 Reduced activity level 2 Increased need for fats 3 Increased food choice 4 Reduced need for sleep
4 Reduced need for sleep As the infant enters the toddler stage, the need for sleep declines, and the activity level increases. Toddlers need less fat and more proteins. Children establish lifetime eating habits during toddlerhood, and there is increased emphasis on food choices.
Which information can be obtained from monitoring the pulmonary artery pressure? 1 Stroke volume 2 Lung function 3 Coronary artery patency 4 Left ventricular functioning
4 Left ventricular functioning The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Pulmonary artery pressure is not a measure of lung function, which is usually tested through spirometry. The patency of the coronary arteries usually is evaluated by cardiac catheterization.
Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Nonrebreather mask
4 Nonorebreather mask The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (up to 90%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L/min. A Venturi mask delivers 24% to 50% oxygen when set at a flow rate of 4 to 10 L/min. A nasal cannula delivers 24% to 45% oxygen when set at a flow rate of 2 to 6 L/min.
Which finding would the nurse recognize as exceeding skill expectations for a preschooler? 1 The child can jump rope. 2 The child can skip on alternate feet. 3 The child can walk up and down steps with ease. 4 The child is able to hold a pencil adeptly and print letters and words.
4 The child is able to hold a pencil adeptly and print letter and words The ability to hold a pencil adeptly and print letters and words is a characteristic of 6-year-old children (school-aged children). A preschooler who exhibits this ability has physical skills greater than his or her age. Preschoolers can jump rope, skip on alternate feet, and walk up and down steps with ease.
The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct. Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds
All of the above Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.
A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? Acidosis Calcium depletion Potassium retention Sodium chloride depletion
Calcium depletion In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.
When caring for a client who has hyponatremia, the nurse would monitor for which symptom? Increased urine output Deep rapid respirations Change in level of consciousness Distended neck veins
Change in level of consciousness A normal sodium level is between 135 and 145 mEq/L (135-145 mmol/L) of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular overhydration, which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue, and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output.
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? Crackles in the lungs Decreased heart rate Decreased BP Cyanosis of nail beds
Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.
Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct. Decreased urine Hypotension Dyspnea Dry mucous membranes Lung crackles Poor skin turgor
Decreased urine Hypotension Dry mucous membranes Poor skin turgor Decreased urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and crackles in the lungs may be caused by fluid overload.
When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct. Intake of ally foods Dietary fat intake Medication compliance Family stresses Recent travel
Intake of salty foods Medication compliance Recent travel Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. Poor adherence to medication used to treat heart failure, such as angiotensin-converting-enzyme inhibitors and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake. Increased or decreased dietary fat intake will not cause fluid retention. Stress is not a contributor to fluid retention.
Which finding for a client who has a potassium level of 2.8 mEq/L (2.8 mmol/L) would be of most concern to the nurse? Abdominal cramps Irregular heart rate Decreased reflexes Muscle weakness
Irregular heart rate The most serious complications of hypokalemia are due to changes in cardiac function, including potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation. Abdominal cramps occur with hypokalemia, but are not fatal. Decreased reflexes occur with hypokalemia, but are not fatal. Muscle weakness occurs with hypokalemia and may progress to paralysis, but is not immediately fatal.
When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply. One, some, or all responses may be correct. Oliguria Dyspnea Hypotension Pulmonary crackles Tenting skin turgor
Oliguria Hypotension Tenting skin turgor With dehydration, the body tries to conserve fluid, resulting in lowered urinary output (oliguria). Dehydration leads to hypovolemia and less circulatory volume, causing decreased cardiac output and hypotension. Fluid volume deficit causes decreased skin turgor and skin tenting when pinched. Difficulty breathing (dyspnea) is a result of pulmonary congestion, which is associated with hypervolemia. Auscultation of crackles is a result of pulmonary congestion, which does not occur with dehydration.
Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? Serum sodium 139 Serum chloride 100 Serum calcium 10.2 Serum potassium 7.2
Serum potassium 7.2 Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).
When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving? Weighing the client Monitoring the intake and output Assessing the extent of pitting edema Asking the client about subjective symptoms
Weighing the client Because 1 liter of fluid weighs approximately 2.2 pounds (1 kg), daily weights are the best way to monitor fluid volume status. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client. Subjective symptoms such as dyspnea may vary for other reasons than fluid balance status.
Which is the expected monthly increase in head circumference from 4 to 6 months of age? 1 1 cm (0.4 inch) 2 2 cm (0.75 inch) 3 0.5 cm (0.2 inch) 4 3.5 cm (1.38 inch)
1 1 cm (0.4 in) Head circumference increases approximately 1 cm (0.4 inch) per month from 4 to 6 months of age. Head circumference increases approximately 2 cm (0.75 inch) per month from birth to 3 months of age. It increases approximately 0.5 cm (0.2 inch) per month during the second 6 months. It does not increase as fast as by 3.5 cm (1.38 inch) at any time during infancy.
Which collaborative action would the emergency department nurse anticipate when a client reports a bicycle accident followed by nasal pain and swelling with difficulty breathing through the nose? 1 Facial x-rays 2 Blood transfusion 3 Oxygen administration 4 Antibiotic administration
1 Facial x-ray The client's history and assessment data indicate possible nasal and facial fractures, and the nurse would anticipate the need for facial x-rays. There is no indication of massive hemorrhage and transfusion is not likely to be needed. Oxygen administration will not be helpful because the client's difficulty breathing is caused by nasal obstruction, not by any lung pathology. Antibiotic administration is not routinely indicated for nasal fractures.
Which stage of Kohlberg's theory of moral development would the nurse anticipate in a client who exhibits absolute obedience to authority and rules? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4
1 Stage 1 Level I, preconventional reasoning, includes stage 1, punishment and obedience training. It is during this stage the nurse would anticipate absolute obedience to authority and rules. Stage 2, also in level I, is when the nurse anticipates that the child will realize there is more than one right view. In stage 3, level II, the child wants to win approval and maintain expectations of his or her immediate group. In stage 4, also in level II, the client expands focus from the relationship with others to societal concerns.
Which instructions would the nurse include when providing teaching to the parents of a child prescribed diuretics? Select all that apply. One, some, or all responses may be correct. Fluid intake should be adequate Diuretics should be taken on an empty stomach Diuretics should be taken at the same time each day Diuretics may interfere with normal labaratory test values Sun or heat exposure should be avoided because of risks of skin darkening
Fluid intake should be adequate Diuretics should be taken at the same time each day Diuretics may interfere with normal laboratory test values The parents should ensure that their child has adequate fluid intake to prevent dehydration. The medication should be taken every day at the same time to facilitate maximum therapeutic action. The parents should be informed that diuretics may interfere with normal laboratory test values such as serum levels of sodium, potassium, magnesium, and chloride. Diuretics should be taken with food or milk to prevent gastric irritation. Sun and heat exposure may cause fluid loss and heat stroke.
When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take first? 1 Establish an airway and stabilize the cervical spine 2 Assess heart sounds and find carotid and femoral pulses 3 Check for alertness, orientation, and pupil reaction to light 4 Remove clothing to enable further assessment of injuries
1 Establish an airway and stabilize the cervical spine The initial actions after a traumatic injury are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment, after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability.
After a nephrectomy, the client arrives in the postanesthesia care unit in the supine position. Which action would the nurse implement to assess the client for signs of hemorrhage? 1 Turn the client to observe the dressings. 2 Press the client's nail beds to assess capillary refill. 3 Observe the client for hemoptysis when suctioning. 4 Monitor the client's blood pressure for a rapid increase.
1 Turn the client to observe the dressings Because of the anatomical position of the incision, drainage will flow by gravity and accumulate under the client lying in the supine position. Nail beds indicate peripheral perfusion, not early hemorrhage. Respiratory hemorrhage is not common after kidney surgery. The blood pressure decreases and the pulse rate increases with hemorrhage.
The nurse would monitor postoperative clients for which clinical manifestations of a pulmonary embolus? Select all that apply. One, some, or all responses may be correct. 1 Somnolence 2 Dyspnea 3 Hemoptysis 4 Bronchial wheezes 5 Feeling of impending doom
2 Dyspnea 3 Hymoptysis 5 Feeling of impending doom Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus typically are apprehensive and hyperalert, not somnolent (the quality or state of being drowsy). Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders, such as asthma.
After observing new-onset restlessness in a client with a swallowing disorder, which action would the nurse take first? 1 Check client orientation. 2 Obtain pulse oximetry. 3 Ask about client anxiety. 4 Test for intact gag reflex.
2 Obtain a pulse oximetry New-onset restlessness may indicate hypoxemia in a client at risk for aspiration, and the nurse would assess oxygenation using pulse oximetry. If oxygen saturation is adequate, the nurse would assess the client's neurological status. If pulse oximetry is in the normal range, the nurse would ask the client about anxiety. The nurse might test for an intact gag reflex in a client with a swallowing disorder, but this would not be the initial action after observing new-onset restlessness.
Which action would the nurse take first when admitting a client, who has had a left-sided pneumonectomy, to the postanesthesia care unit? 1 Check incision and dressing 2 Obtain oxygen saturation 3 Monitor blood pressure and pulse 4 Check chest drainage system for bleeding
2 Obtain oxygen saturation Because assessment and maintenance of respiratory function is the priority in the immediate postoperative period, assessment of respiratory parameters such as oxygen saturation would be done first. The incision and dressings would be assessed for bleeding, but this would be done after assessing respiratory function. Blood pressure and pulse are monitored to help check for bleeding, but this would be done after assessing respiratory function. The chest tube is typically clamped after pneumonectomy, because reinflation of the lung is not needed, and no drainage is expected in the collection chamber.
While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. Which nursing intervention helps prevent complications associated with this condition? 1 Providing thorough perineal care after each voiding 2 Encouraging the client to use the toilet or bedpan every 2 hours 3 Responding quickly to the client's indication of the need to void 4 Applying voiding stimulants to the perineum
2 Secondary The client has secondary syphilis, which occurs 1 to 3 months after healing of the primary lesion and lasts for several weeks to as long as a year; it is the stage at which the individual is most infectious. Primary syphilis is the stage of initial infection and is characterized by the presence of a chancre, a painless lesion at the site of infection. Latent syphilis occurs after the secondary stage and before the late stage of syphilis; in latent syphilis the immune system is able to suppress the infection and there are no clinical signs and symptoms. Tertiary syphilis, also known as late syphilis, is the final stage of syphilis. At this stage, it is a slowly progressive inflammatory disease that can involve many organs; the skin, brain, and heart can be affected.
When preparing to give medications to a client, the nurse notes a prescription for digoxin 2.5 mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which action would the nurse take? 1 Give two tablets. 2 Administer 20 tablets. 3 Clarify why the client is taking digoxin. 4 Consult with the primary health care provider.
4 Consult the primary health care provider The usual dose of digoxin is 0.125 mg to 0.25 mg daily. A dose of 2.5 mg is excessive, and the prescription should be questioned. Two tablets would equal 0.25 mg, which may be the correct prescription, but this will need to be clarified with the primary health care provider. Twenty tablets would equal 2.5 mg, but this would be a toxic dose of digoxin. Clarifying why the digoxin is prescribed would not be useful, because the dose is inappropriate for any diagnosis.
Which nursing action is most accurate when assessing the chest circumference of a newborn? 1 Measuring during expiration only 2 Taking 3 measurements and recording the average 3 Measuring during inspiration and plotting this data on the growth chart 4 Placing the measuring tape around the rib cage at the nipple line
4 Placing the measuring tape around the rib cage at the. Nipple line The most accurate nursing action when assessing the chest circumference of a newborn during the initial physical assessment is to place the measuring tape around the rib cage at the nipple line. Two measurements should be performed: 1 during inspiration and 1 during expiration. The average of these 2 measurements is then plotted on the growth chart.
The nurse assesses an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds
Change in mental status Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the older adult client.
Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? Body weight control Decreased fluid retention Lowering of blood pressure Prevention of hypernatremia
Decreased fluid retention The purpose of a low-sodium diet for clients with heart failure is to decrease fluid retention. Clients with heart failure may or may not need weight loss, but a low-sodium diet will not help with weight control. Although sodium restriction may lower blood pressure in clients with hypertension, because of the Frank-Starling law, lower sodium intake may lead to improved cardiac output and higher blood pressures in clients with heart failure. Dietary sodium intake plays very little role in serum sodium levels (high serum sodium levels is called hypernatremia), which are controlled by multiple hormonal mechanisms, including antidiuretic hormone, aldosterone, and natriuretic peptide.
The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? Skin condition Fluid and electrolyte balance Food intake Fluid intake and output
Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.
When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? Implanted port Midline catheter 18 gauge peripheral venous catheter Peripherally inserted central catheter (PICC) line
PICC Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but require specialized needles and staff who are trained in accessing the port. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.
When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next? Perform a head to toe assessment Place the client on respite flui intake Discuss a restricted sodium diet with the client Document the findings in the health care record
Perform a head to toe assessment Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary crackles associated with left-sided heart failure. More assessment data is needed before deciding whether fluid restrictions are needed for this client. Restricting sodium in the diet is appropriate for most clients with heart failure, but assessment for symptoms of worsening heart failure is a higher priority. Documentation of findings is needed, but not as important as assessing the client for symptoms that may indicate a need for changes in the therapeutic plan.
The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription would the nurse question? Add table salt to each meal Fluid restriction of 1000mL per day Assess neurological status every 2 hours Provide 0.45% sodium chloride (NaCL) IV at 125 mL/hr
Provide 0.45% sodium chloride (NaCL) IV at 125 mL/hr Because 0.45 % NaCl (one-half normal saline) is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. It is important for the nurse to assess for neurological changes.
The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? Pain tolerance Skin turgor Ecchymosis formation Tissue mass
Skin turgor Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.
The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? Clear breath sounds Positive pedal pulse Normal potassium level Decreased urine specific gravity
Clear breath sounds Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.
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. Thirst Seizures Erythema Confusion Constipation
Confusion Seizures Cellular swelling and cerebral edema are associated with hyponatremia; as extracellular sodium level decreases, the cellular fluid becomes relatively more concentrated and pulls water into cerebral cells, leading to confusion and seizures. Thirst is a symptom of hypernatremia; it may indicate dehydration. Erythema is not associated with hyponatremia. Diarrhea, not constipation, is associated with hyponatremia.
The nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. Which assessment will provide the nurse with the most significant data? Weights every day Urinary output every hour Bloop pressure ever 15 min Extent of peripheral edema every 4 hours
Urinary output every hour A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.
A client with end-stage renal disease has an internal arteriovenous fistula in one arm and an external arteriovenous shunt in the other arm. Which difference between the two methods of access will the nurse consider in planning care? 1 The graft is more subject to hemorrhage, clotting, and infection than the fistula is. 2 Blood pressure readings can be taken in the arm with the fistula but not in the one with the shunt. 3 Intravenous (IV) fluids can be administered in the arm with the shunt but not in the one with the fistula. 4 The fistula should have a light dressing, and the shunt should be covered thoroughly with a heavy dressing.
1 The graft is more subject to hemorrhage, clotting, and infection than the fistula is The external shunt may come apart with possible hemorrhage; clotting is a potential hazard. Frequent handling increases the risk of infection. Blood pressure readings should not be obtained in the extremity that has a shunt or fistula because of the pressure exerted on the circulatory system during the procedure. IV fluids should not be infused in the extremity with the shunt or the fistula to avoid pressure from the tourniquet and to lessen the chance of phlebitis. The ends of the shunt cannula should be left exposed for rapid reconnection in the event of disruption.
Which clinical manifestation would the nurse associate with successful fluid replacement therapy? A trended urinary output of at least 30 mL/hr Central venous pressure reading of 1.5 mmHg Baseline pulse rate of 120 bpm, decreased to 110 bpm within 15 min Baseline BP of 50/30 mmHg increases to 70/40 mmHg within 30 min
A trended urinary output of at least 30 mL/hr The nurse would consider a urinary output rate of 30 mL/h adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats/min decreasing to 110 beats/minute within a 15-minute period and a baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period indicates improved tissue perfusion, but not necessarily adequate tissue perfusion. Compensatory mechanisms such as the renin-angiotensin-aldosterone system may continue reabsorption of fluids. Clinical manifestations reflecting adequate tissue perfusion also means the client does not need the compensatory mechanisms any longer, and urinary output increases.
A client with acute kidney failure reports fatigue and becomes lethargic. Upon reviewing the client's medical record, which finding would the nurse determine is the most likely cause of these clinical manifestations? Hyperalemia Hypernatremia A limited fluid intake An increased blood urea nitrogen (BUN) level
An increased BUN An increased BUN level, indicating uremia, is toxic to the central nervous system and causes fatigue and lethargy. Hyperkalemia is associated with muscle weakness, irritability, nausea, and diarrhea. Hypernatremia is associated with firm tissue turgor, oliguria, and agitation. Dehydration can cause fatigue, dry skin and mucous membranes, and rapid pulse and respiratory rates.
A client's sputum smears for acid-fast bacilli (AFB) are positive and requires transmission-based airborne precautions. Which instruction would the nurse teach when orienting the client's visitors? 1 All visitors must wear a gown and gloves. 2 Wear a particulate respirator mask when in the room. 3 Avoid touching objects in the client's room. 4 Limit contact with the client's nonexposed family members.
2 Wear a particulate respirator mask when in the room Tubercle bacilli are transmitted through air currents; therefore personal protective equipment, such as a particulate respirator that filters out organisms as small as 1 µm, is necessary. Gowns and gloves are not necessary. Tuberculosis is spread by airborne microorganisms; gloves are necessary only when touching articles contaminated with respiratory secretions. It is only necessary to avoid contact with objects in the client's room that are contaminated with respiratory secretions. Limiting contact with the client's nonexposed family members is unnecessary.
Which breathing exercises would the nurse teach a client with the diagnosis of emphysema? 1 An inhalation that is prolonged to promote gas exchange 2 Abdominal exercises to limit the use of accessory muscles 3 Sit-ups to help strengthen the accessory muscles of respiration 4 Diaphragmatic exercises to improve contraction of the diaphragm
4 Diaphragmatic. Exercises to improve contraction of the diaphragm diaphragm With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration that are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. One, some, or all responses may be correct. Assessment of skin turgor Documentation of vital signs Assessment of intervention and output Administration of antiemetic meds Replacement of fluid and electrolyte
Assessment of skin turgor Administration of antiemetic meds Replacement of fluid and electrolyte When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic medications; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. Diplopia Skin rash Leg cramp Tachycardia Muscle weakness
Leg cramp Muscle weakness Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.
Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)? Monitor for cardiac dysrhythmias Inquire about changes in bowel patterns Assess for leg muscle twitching or weakness Assess for signs and symptoms of dehydration
Monitor for cardiac dysrhythmias Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.
Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mm Hg? Offer frequent oral fluids for several hours Administer 1 liter of normal saline over 2 hours Give fluid and eletrolytes per nasogastric tube Infuse 500 mL of lactated ringer's solution over 30 min
Offer frequent oral fluids fo several hours Usually the least invasive means possible of rehydration is used for clients needing rehydration. Based on the heart rate and blood pressure, the client has mild dehydration, and oral fluids offered over several hours will improve hydration. Infusion of normal saline could be used, but is more invasive and has a small risk of infection associated with the use of an intravenous catheter. Nasogastric tube use is invasive and uncomfortable and not needed in this alert client, who can swallow liquids. Infusion of electrolyte solutions such as lactated Ringer's solution rapidly also is invasive and places the client at risk of infection.
The nurse reviews the medical record of an older adult client admitted with chronic kidney disease. Which clinical finding is the priority requiring collaboration with the primary health care provider? Lab results sodium: 135 mEq/L Potassium: 6 mEq/L Hemoglobin: 8.5 g/dL Creatinine clearance: 20 mL/min Client interview Client complains of lethargy and fatigue Vitals Temp: 99f Pulse: 84 Respirations: 24 BP: 150/100
Potassium: 6 The client has an increased potassium level outside the expected range for an adult, placing the client at risk for a cardiac dysrhythmia; the higher priority is treatment for the increased potassium, because elevated levels can be lethal. The serum sodium of 135 mEq/L (135 mmol/L) is expected because of the electrolyte imbalance and the anemia related to the decreased production of erythropoietin by the kidney in the presence of chronic kidney failure. A creatinine clearance of 20 mL/min (0.33 mL/s) is low (normal range 95 mL/min in young women; 120 mL/min in young men); however, the client has chronic renal disease and this value reflects the disease process. The priority is the high potassium level. Clients with chronic kidney disease usually have hypertension, and notification is unnecessary.
Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse? The serum potassium level is 3.1 mEq/L The client confused is about to date and time of day The client reports incisional pain at level 8 Chest tube collection chamber has 150 mL of bloody fluid
Serum potassium level is 3.1 mEq/L Hypokalemia is a common complication after CABG and immediate infusion of potassium to correct hypokalemia is needed to prevent postoperative dysrhythmias. Confusion in the immediate postoperative period is common after cardiopulmonary bypass and will be monitored by the nurse, but does not require any other action at this time. Incisional pain is common after CABG and the nurse will administer prescribed pain medications, but pain is not a life-threatening complication. Chest tube drainage of 100 to 200 mL is not unusual in the first hours after CABG; the nurse will monitor the chest tube drainage hourly, but no other action is needed.
When a client in the emergency department has a blood pressure of 90/60 mm Hg, weak quality radial pulse of 108 beats/minute, and reports working outside for several hours on a hot day, which prescribed action would the nurse take first? Complete a head to toe assessment Start infusion of normal saline 500 mL Ask the client about current meds Obtain blood samples for lab testing
Strat infusion of normal saline 500 mL The low blood pressure, tachycardia, and report of being outside for several hours on a hot day suggest hypovolemia, indicating a need for immediate fluid replacement. The head-to-toe assessment is important, but can be completed after the intravenous fluids are started. Asking about the client's usual medications is necessary, but this information would not affect the decision for fluid infusion in this hypovolemic client. The client will need to have blood drawn to check electrolytes and renal function, but the infusion of fluids to prevent complications such as acute kidney injury is the priority.
