ADN 106 Review
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding? "Have you been ingesting large quantities of alcohol?" "Have you been diagnosed with Addison's disease?" "Have you been in the sun a lot?" "Have you been eating a large amount of carotene-rich foods?"
"Have you been eating a large amount of carotene-rich foods?"
The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test? Skin scraping Tzanck smear Patch test Biopsy
Biopsy
The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as scale. erosion. ulcer. fissure.
fissure
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? Concave Brittle Discolored Clubbing
Clubbing
The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak? Shopping mall Swimming pool College dormitory Gymnasium
College dormitory
Which primary lesions are associated with acne caused by sebum blockage in hair follicles? Furuncles Comedones Carbuncles Striae
Comedones
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "I can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed."
"I can use laxatives and enemas but only once a week."
Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will become unconscious." "I will lose the ability to move my legs." "I will be able to hear the surgeon during the surgery." "A needle will deliver the anesthetic into the area around my spinal cord."
"I will become unconscious."
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I won't feel it, but I'll have a tube to help me breathe." "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions."
"I'll be sleepy but able to respond to your questions."
Which statement, if made by the client or family member, would indicate the need for further teaching? "If a skin area gets red but then the red goes away after turning, I should report it to the nurse." "Putting foam pads under the heels or other bony areas can help decrease pressure." "If a person cannot turn himself in bed, someone should help them change positions every 4 hours." "The skin should be washed with only warm water (not hot) and lotion is put on while the skin is a little wet."
"If a person cannot turn himself in bed, someone should help them change positions every 4 hours."
A client asks why a drain is in place to pull fluid from the surgical wound. What is the bestresponse by the nurse? "It assists in preventing infection." "It will cut down on the number of dressing changes needed." "The drain will remove necrotic tissue." "Most surgeons use wound drains now."
"It assists in preventing infection."
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl
0.45% NaCl
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? 0.45% sodium chloride 0.9% sodium chloride 5% glucose in water 5% glucose in normal saline solution
0.45% sodium chloride
Which is considered an isotonic solution? 0.9% normal saline Dextran in normal saline 0.45% normal saline 3% NaCl
0.9% normal saline
Which of these is considered an isotonic solution? 0.9% normal saline Dextran in normal saline 0.45% normal saline 3% NaCl
0.9% normal saline
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? 1 L 500 ml 1500 ml 1250 ml
1 L
Urine Specific Gravity
1.005 - 1.030
What is the normal serum value for sodium?
135 - 145 mEq/L
Below which serum sodium concentration might convulsions or coma occur? 135 mEq/L (135 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)
135 mEq/L (135 mmol/L)
Which of the following patients are at risk for altered Integumentary function? Select all that apply 23 year old with anorexia nervosa 45 year old obese patient with febrile sweats 61 year old s/p renal transplant patient 72 year old patient with congestive heart failure
23 year old with anorexia nervosa 45 year old obese patient with febrile sweats 61 year old s/p renal transplant patient 72 year old patient with congestive heart failure
A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be? <136 mOsm/kg 275-300 mOsm/kg >408 mOsm/kg 350-544 mOsm/kg
275-300 mOsm/kg
What is the normal serum value for potassium?
3.5 - 5.3 mEq/L
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated. a. 0.9% NaCl b. 5% DW c. 0.45% NS d. 3% NS
5% DW
A patient recovering from surgery has an indwelling urinary catheter. The nurse should contact the patient's provider with which of the following 24-hour urine output volumes? 600 mL 750mL 1000mL 1200mL
600mL
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 2 weeks 4 weeks 7 to 10 days 2 to 3 days
7 to 10 days
What percentage of potassium excreted daily leaves the body by way of the kidneys? 20 40 60 80
80
A febrile client's fluid output is in excess of normal because of diaphoresis. What rate of fluid replacement should the nurse plan for the client? 300 mL/24 h 600 mL/24 h 800 mL/24 h 1200 mL/24 h
800 mL/24 h
What is the normal serum value for calcium?
9 - 11 mg/DL
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? <30 mL Between 75 and 100 mL Between 100 and 200 mL >200 mL
<30 mL
Which term describes the transfer of heat from the body to a cooler object in contact with it? Radiation Conduction Lichenification Evaporation
Conduction
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution? Neutral Alkaline Acidic Basic
Acidic
The client who had spinal anesthesia complains of a headache. Which of the following is an inappropriate action by the nurse? Increase fluid intake. Keep the head of the bed flat. Maintain a quiet environment. Administer morphine sulfate.
Administer morphine sulfate.
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Pituitary Adrenal Thyroid Parathyroid
Adrenal
Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? Alcoholism Intestinal resection Inflammatory bowel disease Loss of gastric acid
Alcoholism
In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate? Allow the client to wear dentures. Remove all jewelry. Have the client void. Have client wear hospital gown.
Allow the client to wear dentures.
Which patient is more at risk for an electrolyte imbalance? An 8 month old with a fever of 102.3 ferhinit and diarrhea A 55 year old diabetic with nausea and vomiting A 5 year old with RSV A healthy 87 year old with intermittent episodes of gout
An 8 month old with a fever of 102.3 and diarrhea
A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions? Antiviral Corticosteroids Analgesics Antipyretics
Antiviral
A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase? Discuss with the anesthesiologist the need for higher doses of anesthetic agents. Withhold pain medication due to decreased renal function. Appropriately position the client using adequate padding and support. Maintain an operating room temperature of 18°C to prevent hypothermia.
Appropriately position the client using adequate padding and support.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? Red blood cell count Sputum culture Total hemoglobin Arterial blood gas (ABG) analysis
Arterial blood gas (ABG) analysis
The nurse documents the skin color change of a dark-skinned African American patient in cardiogenic shock as: Ashen gray and dull. Dusky blue. Reddish pink. Whitish pink.
Ashen gray and dull.
The nurse caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include? Avoid cosmetics with fragrance. Wash skin in very hot water. Use a fabric softener. Wear gloves during the day.
Avoid cosmetics with fragrance.
A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face? Use very warm water to clean the face prior to applying the medication. Avoid using the medication around the eyelids because it may cause cataracts and glaucoma. Wash the face several times a day and reapply the medication. Scrape the scaly patches off prior to applying the medication.
Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.
During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? Splinter hemorrhage Beau's line Paronychia Clubbing
Beau's line
The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? PaO2 PO2 Carbonic acid Bicarbonate
Bicarbonate
A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Serum glucose of 90 mg/dL Urine specific gravity of 1.03 Hematocrit level of 48%
Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03
Which is an insensible mechanism of fluid loss? Urination Bowel elimination Breathing Nausea
Breathing
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Circulating nurse Scrub nurse Surgeon Registered nurse first assistant
Circulating nurse
A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? Potassium Phosphorus Calcium Magnesium
Calcium
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? Cardiovascular system Endocrine system Gastrointestinal system Genitourinary system
Cardiovascular system: Depolarizing muscle relaxants can cause cardiac dysrhythmias.
The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for? Red blood cell crenation Red blood cell hydrolysis Cerebral edema Renal failure
Cerebral edema
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Hypertension Slow pulse Jaundice
Chest pain
Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium
Chloride
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations
Confusion
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO 21 mEq/L pH 7.48 PaCO 36 O saturation 95%
pH 7.48
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the mostserious adverse effect of diuretic use? Hyperkalemia Hypokalemia Hypernatremia Hypophosphatemia
Hypokalemia
You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess
Dehydration
The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? Unresponsive to verbal or tactile stimuli Denies sensation to perineum and lower abdomen Yelling and pulling at equipment No movement in right lower leg
Denies sensation to perineum and lower abdomen
The nurse is assisting with positioning the patient on the operating table. The nurse understands that the most commonly used position is which of the following? Lithotomy Sims Trendelenburg Dorsal recumbent
Dorsal recumbent
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? During the preoperative period Upon arrival to the surgical unit Following the surgical procedure At the time of discharge instructions
During the preoperative period
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity
Elevated hematocrit level
Informed consent from the surgical client is essential in all of the following categories of surgery except: Elective surgery Emergent surgery Required surgery Urgent surgery
Emergent surgery
Which term refers to the protrusion of abdominal organs through the surgical incision? Hernia Dehiscence Erythema Evisceration
Evisceration
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Myasthenia gravis Type 1 diabetes mellitus Extreme anxiety Opioid overdose
Extreme anxiety
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? Sebum deficiency Fluid retention Dehydration Protein deficiency
Fluid retention
Hypotonic solution:
Fluid shifts out of the blood into the cell. Rehydrating clients
The nurse is aware that loss of consciousness occurs with which type of anesthesia? General Local Moderate sedation Regional
General
A nurse is assessing a patent's surgical wound. The wound shows beefy, red tissue at the base of the wound and the edges are gaping. Which words best describe this wound? Select all that apply. Fistula Hematoma Granulation Dehiscence
Granulation Dehiscence
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? Hyperkalemia Hypocalcemia Hypokalemia Hypercalcemia
Hypercalcemia
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the mostserious adverse effect of diuretic use? Hyperkalemia Hypokalemia Hypernatremia Hypophosphatemia
Hypokalemia- Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? Hypothalamus Cerebellum Brainstem Thalamus
Hypothalamus
An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? Imagery Optimistic self-recitation Distraction Progressive muscular relaxation
Imagery
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation
Increases arterial pH
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation
Increases arterial pH: Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Summer allergies Cardiovascular compromise Insensible fluid loss
Insensible fluid loss
A patient sits for excessive lengths of time in a wheelchair. Which sites should the nurse assess for skin breakdown? Ischial tuberosities Bilateral scapulae Trochanters Malleoli
Ischial tuberosities
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient? Jaundice Pallor Bronzed appearance Cherry red face
Jaundice
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Nausea or vomiting Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
Light-headedness or paresthesia
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music An On-Q pump Watching television An epidural infusion Changing position
Listening to music Watching television Changing position
A client is undergoing a perineal surgical procedure. The nurse should place the client in which position? Lithotomy Trendelenburg Sims Dorsal recumbent
Lithotomy
While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following? Liver spots Dark discoloration of the skin Bright red moles Hypertrophied scar tissue
Liver spots
Isotonic solution:
Maintain fluid balance; redistribution of body fluid
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis
Metabolic acidosis: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Metabolic alkalosis
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Metabolic alkalosis: A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
Natriuretic peptides secreted:
Na+ reabsorption is inhibited and urine output is increased
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? Yes, this will correct the sodium deficit. Yes, along with the hypotonic IV. No, start with the sodium chloride IV. No, sodium intake should be restricted.
No, sodium intake should be restricted.
The calcium concentration in the blood is regulated by which mechanism? Parathyroid hormone (PTH) Thyroid hormone (TH) Adrenal gland Androgens
Parathyroid hormone (PTH)
A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule? Skin biopsy Skin scrapings Tzanck smear Patch test
Patch test
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Sodium Potassium Calcium Magnesium
Sodium
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery? Nurse Physician Case manager Certified nurse's aide
Physician
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue
Pink to red and soft, bleeding easily
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily White with long, thin areas of scar tissue
Pink to red and soft, noting that it bleeds easily
Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate
Potassium
A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness
Presence of Trousseau sign
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Elevating the head of the bed Reinforcing the dressing or applying pressure if bleeding is frank Monitoring vital signs every 15 minutes Encouraging the client to breathe deeply
Reinforcing the dressing or applying pressure if bleeding is frank
A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Sodium level of 137 mEq/L Potassium level of 3.8 mEq/L Sodium level of 150 mEq/L Potassium level of 6 mEq/L
Sodium level of 150 mEq/L
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse.
Report the infection to an immediate supervisor.
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory alkalosis
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Administering vasopressin as ordered Elevating the head of the client's bed to 90 degrees Restricting sodium intake to 1 gm/day
Restricting fluids to 800 ml/day- Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.
A patient is complaining of severe itching that intensifies at night. The nurse decides to assess the skin using a magnifying glass and penlight to look for the "itch mite." What skin condition does the nurse anticipate finding? Contact dermatitis Pediculosis Scabies Tinea corporis
Scabies
A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas? Sclerae Mucous membranes Nail beds Ear lobes
Sclerae
Which zone of the surgical area only requires attire in the form of scrub clothes and caps? Unrestricted zone Semirestricted zone Restricted zone Operative zone
Semirestricted zone
The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action? Send the client for a chest x-ray. Administer the prescribed IV fluids. Obtain written consent for the procedure. Assess the client's blood pressure (BP) on the right arm.
Send the client for a chest x-ray.
Hypertonic solution:
Shifts fluid into the vascular space. Reduces cerebral edema; expand circulatory volume rapidly.
The client vomits during the surgical procedure. The best action by the nurse is: Increase the IV infusion rate to compensate for lost fluids. Suction the client to remove saliva and gastric secretions. Lower the head of the operating table to promote circulation to the brain. Administer an anti-emetic to alleviate nausea.
Suction the client to remove saliva and gastric secretions.
Which of the following techniques least exhibits surgical asepsis? Adding only sterile items to a sterile field Keeping sterile gloved hands above the waist Suctioning the nasopharyngeal cavity of a client Placing the sterile field at least one foot away from personnel
Suctioning the nasopharyngeal cavity of a client
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? Surgeon Circulating nurse Scrub nurse Anesthetist
Surgeon
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Bradycardia Tachycardia Vasodilation Increased urine output
Tachycardia
The patient has had recent bilateral, above the knee amputations and has developed C. difficile diarrhea. What assessments should the nurse do to detect EVC in this patient? Tenting Measure rate & character of pulse Measure postural blood pressure and heart rate Check for Trousseau's signs Observe for flatness of neck veins when upright Observe for flatness of neck veins when supine
Tenting Measure rate & character of pulse Measure postural blood pressure and heart rate Observe for flatness of neck veins when supine
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client can be discharged from the PACU. The client must remain in the PACU. The client should be transferred to an intensive care area. The client must be put on immediate life support.
The client can be discharged from the PACU.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? The client sees his physician for a check-up yearly. The client has never traveled outside of the country. The client had a liver transplant 2 years ago. The client works in a health care insurance office.
The client had a liver transplant 2 years ago.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the fall in pH? The lungs are unable to breathe in sufficient oxygen. The lungs are unable to exchange oxygen and carbon dioxide. The lungs have ineffective cilia from years of smoking. The lungs are not able to blow off carbon dioxide
The lungs are not able to blow off carbon dioxide
A nurse is assessing a new colostomy stoma, finding it beefy, red, and moist though the surrounding skin appears intact. What should the nurse conclude? The patient' is developing an infection The patient is developing maceration at the site The site is healing appropriately The stony wafer and pouch have been too tight
The site is healing appropriately
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad A frozen, packaged low-fat dinner with a side salad Tomato juice, low-fat cottage cheese, and three slices of bacon
Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad
Which term describes a fungal infection of the scalp? Tinea capitis Tinea corporis Tinea cruris Tinea pedis
Tinea capitis
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is: To have the client sign the consent immediately To have the client's next of kin sign the consent For the nurse to sign the consent with verbal permission of the client To notify the surgeon
To notify the surgeon
The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? A biopsy A face-lift Tumor excision Placement of gastrostomy tube
Tumor excision
A patient with an existing pressure ulcer is scheduled for surgery. Which of the following interventions would be appropriate for this patent postoperatively? Select all that apply. Turn and position every 2 hours Pressure relief bed surface Silver dressings Debridement
Turn and position every 2 hours Pressure relief bed surface
A patient is found to have broken skin on his coccyx that has black eschar covering the base of the wound. How is the wound stage? Stage I Stage II Stage III Unstageable
Unstageable
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.02 Urine pH of 3.0 Absence of protein Absence of glucose
Urine pH of 3.0
A young college student recently had her tongue and lip pierced. She has developed a superinfection of candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for her? Use an antifungal mouthwash or salt water. Use a soft-bristled toothbrush. Rinse the mouth after eating food. Move the piercing back and forth during washing.
Use an antifungal mouthwash or salt water.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing. Use chest breathing.
Use diaphragmatic breathing.
Select the nutrient that is important for postoperative wound healing because it helps form collagen. Protein Vitamin C Magnesium Vitamin A
Vitamin C
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system
bicarbonate-carbonic acid buffer system
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 130 mEq/L (130 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is consistent with the client's symptom? sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L)
calcium 12.9 mg/dL (3.2 mmol/L)
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 130 mEq/L (130 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is consistent with the client's symptoms? sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L)
calcium 12.9 mg/dL (3.2 mmol/L)- More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion. The listed sodium, potassium, and chloride levels are within normal limits.
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: continuously monitors the sedated client. performs a complete assessment of the client. obtains a surgical consent from the client's mother. assesses how well the client is recovering from anesthesia.
continuously monitors the sedated client.
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia
dehydration
The purpose of melanin is to: determine skin color. form a callus where the skin is subjected to friction. assist in transfer of heat through contact. prevent drying and cracking of the skin and hair.
determine skin color.
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? furosemide hydrochlorothiazide metolazone spironolactone
furosemide
A client with mild fluid volume excess is prescribed a diuretic that blocks sodium reabsorption in the distal tubule. Which diuretic does the nurse anticipate administering to this client? bumetanide torsemide hydrochlorothiazide furosemide
hydrochlorothiazide
Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.
increased breathing effort and weight gain.
A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the malignancy is causing the electrolyte imbalance. client's diet is lacking in calcium-rich food products. client may be developing hyperaldosteronism. client has a history of alcohol abuse.
malignancy is causing the electrolyte imbalance.: The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? malignant hyperthermia hypothermia infection fluid volume excess
malignant hyperthermia
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole ondansetron ranitidine
ondansetron
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? osmosis filtration evaporation active transport
osmosis
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
pH PaCO2 HCO3
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
pH, 7.25; PaCO2 50 mm Hg
Which arterial blood gas (ABG) result would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28
Antidiuretic hormone secreted:
reabsorption of water
Aldosterone secreted:
tells kidneys to reabsorbs Na+
The nurse teaches the client who demonstrates herpes zoster (shingles) that once a client has had shingles, they will not have it a second time. a person who has had chickenpox can contract it again upon exposure to a person with shingles. the infection results from reactivation of the chickenpox virus. no known medications affect the course of shingles.
the infection results from reactivation of the chickenpox virus
A patient's blood osmolarity is 302 mOsm/L. What manifestation does the nurse expect to see in this patient? increased urine thirst peripheral edema nausea
thirst
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? tingling sensation in the fingers polyuria flank pain hypertension
tingling sensation in the fingers
The nurse is caring for a client with herpes zoster. The nurse documents the lesions as vesicles. wheals. pustules. cysts.
vesicles.
