Adult Health 1 - Exam 4

CH. 44 - A patient with suspected renal insufficiency is scheduled for a creatinine clearance diagnostic test. Which instructions would be appropriate for the nurse to provide to the patient? a. "Empty your bladder and discard the urine; then save all urine for 24 hours." b. "Your blood creatinine level will be tested after you eat a high-protein meal." c. "This test should not be performed if you have allergies to iodine or shellfish." d. "A sterile container must be used to store the urine during the collection period.

a. "Empty your bladder and discard the urine; then save all urine for 24 hours." The patient should discard the first urination when this test is started. Urine should be saved from all subsequent urinations for 24 hours. Creatinine clearance testing does not involve the injection of contrast dye. A serum creatinine is determined during the 24-hour period and used in the calculation to determine creatinine clearance. Consumption of a high-protein meal is not indicated. Sterile containers would be indicated if cultures are performed to determine the presence of microorganisms.

CH. 48 - The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which statement by the patient requires an intervention by the nurse? a. "I will discard any insulin bottle that is cloudy in appearance." b. "The best injection site for insulin administration is in my abdomen." c. "I can wash the site with soap and water before insulin administration." d. "I may keep my insulin at room temperature (75° F) for up to 1 month."

a. "I will discard any insulin bottle that is cloudy in appearance." Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

CH. 64 - A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? a. "Infertility can result from some medications used to control your disease." b. "Temporary remission of your signs and symptoms is common during pregnancy." c. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." d. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

a. "Infertility can result from some medications used to control your disease." Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

CH. 16 - When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. The nurse suspects that the patient may be experiencing what complication? a. Air embolism b. Catheter occlusion c. Insertion site trauma d. Precipitate build up in lumen

a. Air embolism The cap off the central line could allow entry of air into the circulation, causing an air embolus. Catheter occlusion, precipitate build up in lumen manifest with sluggish infusions. Insertion site trauma manifests with edema near the insertion site and dysrhythmias.

CH. 62 - A nurse performs discharge teaching for a patient after a left hip arthroplasty using the posterior approach. Which statement indicates teaching is successful? a. "Leg-raising exercises are necessary for several months." b. "I should not try to drive a motor vehicle for 2 to 3 weeks." c. "I will not have any restrictions now on hip and leg movements." d. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

a. "Leg-raising exercises are necessary for several months." Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

CH. 49 - The nurse is teaching a patient with acromegaly from an unresectable benign pituitary tumor about octreotide therapy. The nurse should provide further teaching if the patient makes which statement? a. "The provider will infuse this medication through an IV." b. "I will inject the medication in the subcutaneous layer of the skin." c. "The medication should decrease the growth hormone production to normal." d. "I will have my growth hormone level measured every 2 weeks for several weeks."

a. "The provider will infuse this medication through an IV." Drug therapy is an option for patients whose tumors are not surgically resectable. The primary drug used is octreotide, a somatostatin analog. It reduces growth hormone (GH) levels to normal in many patients. Octreotide is given by subcutaneous injection three times a week. GH levels are measured every 2 weeks to K guide drug dosing, and then every 6 months until the desired response is obtained.

CH. 44 - A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure? a. "You might have pink-tinged urine and burning after your cystoscopy." b. "You'll need to refrain from eating or drinking after midnight the day before the test." c. "The morning of the test, you will drink some water that contains a contrast solution." d. "You'll need a urinary catheter before the cystoscopy, and it will be in place for a few days."

a. "You might have pink-tinged urine and burning after your cystoscopy." Pink-tinged urine, burning, and frequency are common after a cystoscopy. The patient does not need to be NPO before the test, and contrast media is not needed. A cystoscopy does not always necessitate catheterization before or after the procedure.

CH. 16 - A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? a. 0.45% saline b. 0.9% saline c. Packed red blood cells d. Lactated Ringer's solution

a. 0.45% saline IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

CH. 16 - Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.5 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L

a. 3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus, the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.

CH. 48 - The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes? a. A 48-yr-old woman with a hemoglobin A1C of 8.4% b. A 58-yr-old man with a fasting blood glucose of 111 mg/dL c. A 68-yr-old woman with a random plasma glucose of 190 mg/dL d. A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

a. A 48-yr-old woman with a hemoglobin A1C of 8.4% Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.

CH. 55 - In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? a. A 50-yr-old woman with lethargy from a drug overdose b. A 40-yr-old man with a complete lumbar spinal cord injury c. A 60-yr-old man with severe pain from trigeminal neuralgia d. A 30-yr-old woman with a high fever and bacterial meningitis

a. A 50-yr-old woman with lethargy from a drug overdose The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

CH. 20 - Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? a. Absence of pain or pressure b. Blurred vision in the morning c. Seeing colored halos around lights d. Eye pain accompanied with nausea and vomiting

a. Absence of pain or pressure Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before a diagnosis is made unless regular eye examinations are being performed. Primary angle-closure glaucoma signs and symptoms include sudden, excruciating pain in or around the eye, seeing colored halos around lights, and nausea and vomiting.

CH. 44 - The nurse is preparing a patient for an intravenous pyelogram (IVP). What is a priority action by the nurse? a. Administer a cathartic or enema. b. Assess patient for allergies to penicillin. c. Keep the patient NPO for 4 hours preprocedure. d. Tell the patient a metallic taste be present during the procedure.

a. Administer a cathartic or enema. Nursing responsibilities in caring for a patient undergoing an IVP include administration of a cathartic or enema to empty the colon of feces and gas. The nurse will also assess the patient for iodine sensitivity; keep the patient NPO for 8 hours before the procedure; and advise the patient that warmth, a flushed face, and a salty taste during injection of contrast material may occur.

CH. 20 - The patient reports a loss of central vision. What test should the nurse teach the patient about to identify changes in macular function? a. Amsler grid test b. B-scan ultrasonography c. Fluorescein angiography d. Intraocular pressure testing with Tono-Pen

a. Amsler grid test The Amsler grid test is self-administered and regular testing is necessary to identify any changes in macular function. B-scan ultrasonography is used to diagnose ocular pathologic conditions (e.g., intraocular foreign bodies or tumors, vitreous opacities, retinal detachments). Fluorescein angiography is used to diagnose problems related to the flow of blood through pigment epithelial and retinal vessels. Intraocular pressure testing with a Tono-Pen is done to test for glaucoma.

CH. 29 - The nurse is caring for a 36-yr-old patient receiving phenytoin (Dilantin) to treat seizures resulting from a traumatic brain injury as a teenager. It is most important for the nurse to observe for which hematologic adverse effect of this medication? a. Anemia b. Leukemia c. Polycythemia d. Thrombocytosis

a. Anemia Hematologic adverse effects of phenytoin include anemia, thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia.

CH. 62 - The patient with frostbite on the distal toes of both feet is scheduled for amputation of the damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? a. Arteriogram showing blood vessels b. Peripheral pulse palpation bilaterally c. Patches of black, indurated, cold tissue d. Bilateral pale, cool skin below the ankles

a. Arteriogram showing blood vessels Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops, and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

CH. 55 - The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient? a. Ask the patient a question such as, "Who were the last 3 presidents?" b. Evaluate level of consciousness, body posture, and facial expressions. c. Observe for signs of agitation, anger, or depression during the health check. d. Request that the patient mimic rapid alternating movements with both hands.

a. Ask the patient a question such as, "Who were the last 3 presidents?" Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination. It may include testing rapid alternating movements of the upper and lower extremities.

CH. 55 - The nurse is caring for a patient after a lumbar puncture. Which should be a priority action by the nurse? a. Assess for drainage or bleeding from the puncture site. b. Monitor for bladder problems and bowel incontinence. c. Maintain bed rest until lower extremities move normally. d. Check for loss of muscle strength in the upper extremities.

a. Assess for drainage or bleeding from the puncture site. After a lumbar puncture, the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.

CH. 31 - A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments are appropriate for this patient? (Select all that apply.) a. Assess for return of gag reflex. b. Assess groin for hematoma or bleeding. c. Monitor vital signs and oxygen saturation. d. Position patient supine with head of bed flat. e. Assess lower extremities for circulatory compromise.

a. Assess for return of gag reflex. c. Monitor vital signs and oxygen saturation. The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and oxygen saturation are important assessment parameters resulting from the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels. Therefore it is not necessary to monitor the patient's groin and lower extremities in relation to this procedure or to maintain a flat position.

CH. 48 - The nurse is assigned to care for a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in managing diabetes, what should be the nurse's initial intervention? a. Assess patient's perception of what it means to have diabetes. b. Ask the patient to write down current knowledge about diabetes. c. Set goals for the patient to actively participate in managing his diabetes. d. Assume responsibility for all of the patient's care to decrease stress level.

a. Assess patient's perception of what it means to have diabetes. For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

CH. 55 - When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? a. Ataxia b. Apraxia c. Anisocoria d. Anosognosia

a. Ataxia Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

CH. 31 - The nurse determines that a patient's pedal pulses are absent. What factor could contribute to this finding? a. Atherosclerosis b. Hyperthyroidism c. Atrial dysrhythmias d. Arteriovenous fistula

a. Atherosclerosis Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.

CH. 25 - The nurse is performing a focused respiratory assessment of a patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? a. Auscultation of bilateral breath sounds b. Percussion of anterior and posterior chest wall c. Palpation of the chest bilaterally for tactile fremitus d. Inspection for anterior and posterior chest expansion

a. Auscultation of bilateral breath sounds Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

CH. 49 - Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? (Select all that apply.) a. BP 80/50 b. Heart rate 54 c. Glucose 63 mg/dL d. Sodium 148 mEq/L e. Potassium 6.3 mEq/L f. Temperature 101.1° F

a. BP 80/50 c. Glucose 63 mg/dL e. Potassium 6.3 mEq/L f. Temperature 101.1° F Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. During acute adrenal insufficiency, the patient exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies, including hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

CH. 25 - A frail older adult patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? a. Bases of the posterior chest area b. Apices of the posterior lung fields c. Anterior chest area above the breasts d. Midaxillary on the left side of the chest

a. Bases of the posterior chest area Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

CH. 44 - A postoperative patient had a urinary catheter. Eight hours after catheter removal and drinking fluids, the patient has not been able to void. What is the nurse's first action to assess for urinary retention? a. Bladder scan b. Cystometrogram c. Residual urine test d. Kidneys, ureters, bladder (KUB) x-ray

a. Bladder scan If the patient is unable to void, the bladder may be palpated for distention or percussed for dullness if it is full, or a bladder scan may be done to determine the approximate amount of urine in the bladder. A cystometrogram visualizes the bladder and evaluates vesicoureteral reflux. A KUB x-ray delineates size, shape, and positions of kidneys and possibly a full bladder. Neither of these would be useful in this situation. A residual urine test requires urination before catheterizing the patient to determine the amount of urine left in the bladder, so this assessment would not be helpful for this patient.

CH. 31 - The nurse is providing care for a patient who has decreased cardiac output due to heart failure. As a basis for planning care, what should the nurse understand about cardiac output (CO)? a. CO is calculated by multiplying the patient's stroke volume by the heart rate. b. CO is the average amount of blood ejected during one complete cardiac cycle. c. CO is determined by measuring the electrical activity of the heart and the heart rate. d. CO is the patient's average resting heart rate multiplied by the mean arterial blood pressure.

a. CO is calculated by multiplying the patient's stroke volume by the heart rate. Cardiac output is determined by multiplying the patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.

CH. 64 - A patient with longstanding Raynaud's phenomenon currently reports red spots on the hands, forearms, palms, face, and lips. Which additional findings would the nurse expect? (Select all that apply.) a. Calcinosis b. Weight loss c. Sclerodactyly d. Difficulty swallowing e. Weakened leg muscles f. Skin thickening below the elbow and knee

a. Calcinosis c. Sclerodactyly d. Difficulty swallowing f. Skin thickening below the elbow and knee This patient is at risk for scleroderma. The acronym CREST represents the manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud's phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

CH. 48 - The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? a. Cheese b. Broccoli c. Chicken d. Oranges

a. Cheese Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

CH. 48 - The nurse has been teaching a patient with diabetes how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? a. Chooses a puncture site in the center of the finger pad. b. Washes hands with soap and water to cleanse the site to be used. c. Warms the finger before puncturing the finger to obtain a drop of blood. d. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

a. Chooses a puncture site in the center of the finger pad. The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

CH. 25 - When assessing the patient in acute respiratory distress, what should the nurse expect to observe? (Select all that apply.) a. Cyanosis b. Tripod position c. Kussmaul respirations d. Accessory muscle use e. Increased AP diameter

a. Cyanosis d. Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

CH. 20 - The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? a. Discard all opened or used lens care products. b. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. c. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. d. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

a. Discard all opened or used lens care products. The patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products. The risk of conjunctivitis is increased with not disinfecting lenses properly, wearing contact lenses too long, or using water or homemade solutions to store and clean lenses.

CH. 20 - A college student reports eye pain after studying for finals. What assessment should the nurse make first in determining the possible cause of this eye pain? a. Do you wear contacts? b. Do you have any allergies? c. When was your last eye exam? d. Describe the changes in your vision.

a. Do you wear contacts? College students frequently wear contact lenses and stay up late or all night studying for finals. If the student wears contacts, the wearing of them while studying, care of them, and length of wear time will be assessed before looking for a corneal abrasion from extended wear with fluorescein dye. There are no manifestations of allergies or visual changes mentioned.

CH. 21 - A patient reporting frequent vertigo is scheduled for electronystagmography to test vestibular function. Which instructions should the nurse provide to the patient before the procedure? a. Eat a light meal before the procedure. b. Avoid carbonated beverages before the procedure. c. Take nothing by mouth for 3 hours before the procedure. d. No special dietary restrictions are needed until after the procedure.

a. Eat a light meal before the procedure. Teach patient to eat a light meal before the test to avoid nausea. Results of vestibular tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo drugs.

CH. 64 - The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient's choice of which food item indicates an understanding of the instructions? a. Eggs b. Liver c. Salmon d. Chicken

a. Eggs Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

CH. 62 - A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate? a. Elevate the right arm on 2 pillows for 24 hours. b. Apply heating pad to reduce muscle spasms and pain. c. Limit movement of the thumb and fingers on the right hand. d. Place arm in a sling to prevent movement of the right shoulder.

a. Elevate the right arm on 2 pillows for 24 hours. The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

CH. 48 - The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis? a. Excessive thirst b. Gradual weight gain c. Overwhelming fatigue d. Recurrent blurred vision

a. Excessive thirst The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

CH. 49 - The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? a. Expect to have some nasal irritation while using this drug. b. Monitor for symptoms of hypernatremia as a drug side effect. c. Report any decrease in urinary output to the health care provider. d. Drink at least 3000 mL of water per day while taking this medication.

a. Expect to have some nasal irritation while using this drug. Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

CH. 49 - The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient has which manifestations? a. Facial muscle spasms and laryngospasms b. Tingling in the hands and around the mouth c. Decreased muscle tone and muscle weakness d. Shortened QT interval on the electrocardiogram

a. Facial muscle spasms and laryngospasms Nursing care for a patient after a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are manifestations of hyperparathyroidism.

CH. 25 - What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? a. Fingernails b. Chest excursion c. Spinal curvatures d. Respiratory pattern

a. Fingernails Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

CH. 44 - A patient was admitted 2 weeks ago after multiple traumatic injuries in a motor vehicle collision. The patient now has a serum creatinine at 3.9 mg/dL and blood urea nitrogen (BUN) of 100 mg/dL. Which medication, if ordered by the health care provider, should the nurse question? a. Gentamicin b. Nitrofurantoin c. Acetaminophen d. Morphine sulfate

a. Gentamicin Elevated serum creatinine and BUN indicate renal insufficiency or acute kidney injury. All medications should be evaluated for nephrotoxic potential. Many drugs are known to be nephrotoxic (see Table 44.3); gentamicin is a potential nephrotoxic agent.

CH. 21 - A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? a. Hearing loss b. Exophthalmos c. Conjunctivitis d. Recurrent fever

a. Hearing loss Aminoglycosides such as gentamicin are drugs that are potentially ototoxic and may cause damage to the auditory nerve. When this drug is used, careful monitoring for hearing and balance problems (e.g., hearing loss, tinnitus, vertigo) is essential. Exophthalmos is related to a symptom of hyperthyroidism. Conjunctivitis is a bacterial or a viral infection of the conjunctiva. Recurrent fever can be related to many issues and is not related to the use of IV gentamicin.

CH. 20 - The nurse is assessing a patient's medical history. What aspects of the patient's medical history are most likely to have potential consequences for the patient's visual system? a. Hypertension and diabetes b. Hypothyroidism and polycythemia c. Atrial fibrillation and atherosclerosis d. Vascular dementia and chronic fatigue

a. Hypertension and diabetes Hypertension and diabetes frequently contribute to visual pathologies. The other health problems are less likely to have a direct, deleterious effect on a patient's vision.

CH. 31 - A patient with a history of myocardial infarction is scheduled for a transesophageal echocardiogram to visualize a suspected clot in the left atrium. What information should the nurse include when teaching the patient about this diagnostic study? a. IV sedation may be administered to help the patient relax. b. Food and fluids are restricted for 2 hours before the procedure. c. Ambulation is restricted for up to 6 hours before the procedure. d. Contrast medium is injected into the esophagus to enhance images.

a. IV sedation may be administered to help the patient relax. IV sedation is administered to help the patient relax and ease the insertion of the tube into the esophagus. Food and fluids are restricted for at least 6 hours before the procedure. Smoking and exercise are restricted for 3 hours before exercise or stress testing but not before TEE. Contrast medium is administered IV to evaluate the direction of blood flow if a septal defect is suspected.

CH. 55 - The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation should the nurse assess in this patient? a. Impaired muscle movement b. Decreased Deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature

a. Impaired muscle movement Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.

CH. 29 - The patient diagnosed with anemia had laboratory tests done. Which results indicate a lack of nutrients needed to produce new red blood cells (RBCs)? (Select all that apply.) a. Increased homocysteine b. Decreased reticulocyte count c. Decreased cobalamin (vitamin B12) d. Increased methylmalonic acid (MMA) e. Elevated erythrocyte sedimentation rate (ESR)

a. Increased homocysteine c. Decreased cobalamin (vitamin B12) d. Increased methylmalonic acid (MMA) Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.

CH. 48 - The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? a. Increased triglyceride levels b. Increased high-density lipoproteins (HDL) c. Decreased low-density lipoproteins (LDL) d. Decreased very-low-density lipoproteins (VLDL)

a. Increased triglyceride levels Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

CH. 29 - Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse recognizes that this diagnostic finding suggests which problem? a. Infection b. Hypoxemia c. Acute thrombotic event d. Risk of hypocoagulation

a. Infection An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

CH. 49 - The nurse is caring for a patient receiving high-dose oral corticosteroid therapy after a kidney transplant. Which side effect would the nurse monitor for as it presents the greatest risk? a. Infection b. Low blood pressure c. Increased urine output d. Decreased blood glucose

a. Infection Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreasing urine output), hypertension, and hyperglycemia.

CH. 31 - What position should the nurse place the patient in to auscultate for signs of acute pericarditis? a. Supine without a pillow b. Sitting and leaning forward c. Left lateral side-lying position d. Head of bed at a 45-degree angle

b. Sitting and leaning forward A pericardial friction rub indicates pericarditis. To auscultate a pericardial friction rub, the patient should be sitting and leaning forward. The nurse will hear the pericardial friction rub at the end of expiration.

CH. 29 - When evaluating a patient's nutritional-metabolic pattern related to hematologic health, what priority assessment should the nurse perform? a. Inspect the skin for petechiae. b. Ask the patient about joint pain. c. Assess for vitamin C deficiency. d. Determine if the patient can perform activities of daily living.

a. Inspect the skin for petechiae. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.

CH. 25 - When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient? (Select all that apply.) a. Is it hard for you to fall asleep? b. Do you awaken abruptly during the night? c. Do you sleep more than 8 hours per night? d. Do you need to sleep with the head elevated? e. Do you often need to urinate during the night?

a. Is it hard for you to fall asleep? b. Do you awaken abruptly during the night? d. Do you need to sleep with the head elevated? A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

CH. 21 - An older adult patient states they do not seem to hear well and have to ask people to repeat themselves. What should the nurse do first to determine the cause of the hearing loss? a. Look for cerumen in the ear. b. Assess for increased hair growth in the ear. c. Tell the patient it is probably related to aging. d. Ask the patient if he has fallen because of dizziness.

a. Look for cerumen in the ear. Gerontologic differences in the assessment of the auditory system include increased production of and drier cerumen, which can become impacted in the ear canal and contribute to hearing loss. Conductive hearing loss with impacted cerumen may lead to speaking softly as the patient's voice conducted through bone seems loud to the patient. Although increased hair growth occurs, it will not impact the hearing. Presbycusis may be occurring, but it should not be assumed. There is no reason to ask the patient if he has fallen because dizziness and vertigo are not a normal change of aging of the ear.

CH. 16 - A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply.) a. Lung sounds b. Bowel sounds c. Blood pressure d. Serum sodium level e. Serum potassium level

a. Lung sounds c. Blood pressure d. Serum sodium level Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

CH. 64 - A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments would be included in the plan of care? (Select all that apply.) a. Massage therapy b. Low-impact aerobic exercise c. Relaxation strategy (biofeedback) d. Antiseizure drug pregabalin (Lyrica) e. Morphine sulfate extended-release tablets f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

a. Massage therapy b. Low-impact aerobic exercise c. Relaxation strategy (biofeedback) d. Antiseizure drug pregabalin (Lyrica) f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft]) Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain at the knees. Relaxation using biofeedback may decrease the patient's stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are avoided unless other medications do not relieve pain.

CH. 25 - A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? a. Monitor the patient for laryngeal edema. b. Assess the patient's level of consciousness. c. Monitor and manage the patient's level of pain. d. Assess the patient's heart rate and blood pressure.

a. Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

CH. 49 - The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which manifestations would represent the expected electrolyte imbalance? (Select all that apply.) a. Nausea and vomiting b. Neurologic irritability c. Lethargy and weakness d. Increasing urine output e. Hyperactive bowel sounds

a. Nausea and vomiting c. Lethargy and weakness d. Increasing urine output Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability and hyperactive bowel sounds do not occur with hypercalcemia.

CH. 62 - A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? a. Notify the health care provider immediately. b. Elevate the left leg above the level of the heart. c. Administer prescribed morphine sulfate intravenously. d. Apply ice packs to the left proximal tibia over the cast.

a. Notify the health care provider immediately. Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

CH. 49 - The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should be included in the plan of care? (Select all that apply.) a. Obtain daily weights. b. Limit fluids to 1000 mL/day. c. Administer diuretics as ordered. d. Monitor for signs of hypernatremia. e. Minimize turning and range of motion. f. Elevate the head of the bed at 10 degrees or less.

a. Obtain daily weights. b. Limit fluids to 1000 mL/day. c. Administer diuretics as ordered. f. Elevate the head of the bed at 10 degrees or less. The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

CH. 49 - What is a nursing priority when caring for a patient with hypothyroidism? a. Patient teaching related to levothyroxine b. Providing a dark, low-stimulation environment c. Closely monitoring the patient's intake and output d. Initiating precautions related to radioactive iodine therapy

a. Patient teaching related to levothyroxine A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine. It is not necessary to closely monitor intake and output. Low stimulation and radioactive iodine therapy are used to treat hyperthyroidism.

CH. 64 - Four patients have been newly diagnosed with connective tissue disorders. The nurse is concerned with safety issues and interstitial lung involvement for the patient with which diagnosis? a. Polymyositis b. Reactive arthritis c. Sjögren's syndrome d. Systemic lupus erythematosus (SLE)

a. Polymyositis Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient's risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter's syndrome) or Sjögren's syndrome. Safety may be an issue later in disease progression of SLE.

CH. 64 - A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (Select all that apply.) a. Presence of nodules b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankyloses f. Joint space narrowing and formation of osteophytes

a. Presence of nodules e. Subluxation of joints without fibrous ankyloses In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

CH. 62 - The nurse is caring for a patient who had a left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? a. Progressive leg exercises to obtain 90-degree flexion b. Early ambulation with full weight bearing on the left leg c. Bed rest for 3 days with the left leg immobilized in extension d. Immobilization of the left knee in 30-degree flexion to prevent dislocation

a. Progressive leg exercises to obtain 90-degree flexion The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

CH. 29 - Which assessment finding would support the presence of a hemostasis abnormality? a. Purpura b. Pruritus c. Weakness d. Pale conjunctiva

a. Purpura Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low hemoglobin level.

CH. 44 - In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to maintaining homeostasis. Which physiologic processes are performed by the kidneys? (Select all that apply.) a. Release of renin b. Activation of vitamin D c. Carbohydrate metabolism d. Erythropoietin production e. Hemolysis of old red blood cells (RBCs)

a. Release of renin b. Activation of vitamin D d. Erythropoietin production In addition to urine formation, the kidneys release renin to maintain blood pressure, activate vitamin D to maintain calcium levels, and produce erythropoietin to stimulate RBC production. Carbohydrate metabolism and hemolysis of old RBCs are not physiologic functions that are performed by the kidneys.

CH. 16 - A patient is admitted with metabolic acidosis. Which system is not functioning normally? a. Renal system b. Buffer system c. Endocrine system d. Respiratory system

a. Renal system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes HCl acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

CH. 25 - The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient? a. Restlessness, tachypnea, tachycardia, and diaphoresis b. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis c. Combativeness, retractions with breathing, cyanosis, and decreased output d. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

a. Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue are later manifestations of inadequate oxygenation.

CH. 44 - The nurse is caring for a patient after a right kidney biopsy. Which position would be the most appropriate for this patient immediately after the procedure? a. Right lateral side-lying position b. Reverse Trendelenburg position c. Supine with lower extremities elevated d. High Fowler's position with arms supported

a. Right lateral side-lying position After a renal biopsy, a pressure dressing should be applied. The patient should be kept on the affected side for 30 to 60 minutes to apply additional pressure from the patient's own body weight and then on bed rest for 24 hours. High Fowler's position with arms supported is a position for a patient in respiratory distress. Reverse Trendelenburg position is used to maintain circulation to the legs in peripheral artery insufficiency. Supine with legs elevated puts excessive pressure on the diaphragm and should generally be avoided.

CH. 31 - What age-related cardiovascular changes should the nurse assess for when providing care to an older adult patient? (Select all that apply.) a. Systolic murmur b. Diminished pedal pulses c. Increased maximal heart rate d. Decreased maximal heart rate e. Increased recovery time from activity

a. Systolic murmur b. Diminished pedal pulses d. Decreased maximal heart rate e. Increased recovery time from activity Well-documented cardiovascular effects of the aging process include valvular rigidity leading to systolic murmur, arterial stiffening leading to diminished pedal pulses or possible increased blood pressure, and an increased amount of time that is required for recovery from activity. Maximal heart rate tends to decrease rather than increase with age related to cellular aging and fibrosis of the conduction system.

CH. 48 - A patient is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.) a. The level is consistent with renal insufficiency from renal nephropathy. b. The level may be high because of dehydration that accompanies hyperglycemia. c. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. d. The patient may be excreting sodium and retaining potassium from malnutrition. e. This level shows adequate treatment of the cellulitis and acceptable glucose control.

a. The level is consistent with renal insufficiency from renal nephropathy. b. The level may be high because of dehydration that accompanies hyperglycemia. c. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient's potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.

CH. 16 - You are caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) a. The potassium level may be increased if the patient has nephropathy. b. The patient has been eating excessive amounts of foods that increase potassium levels. c. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. d. There may be excess potassium being released into the blood as a result of massive blood transfusion. e. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

a. The potassium level may be increased if the patient has nephropathy. d. There may be excess potassium being released into the blood as a result of massive blood transfusion. e. The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have a nasogastric tube and not be eating.

CH. 29 - The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient? a. Tiny purple spots on the skin b. Large ecchymotic areas on the skin c. Hyperkeratotic papules and plaques d. Small, raised red areas on the soles of the feet

a. Tiny purple spots on the skin Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

CH. 62 - An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? a. Use mirror therapy. b. Give opioid analgesics. c. Rebandage the residual limb. d. Show the patient the leg is gone.

a. Use mirror therapy. Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

CH. 16 - While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? (Select all that apply.) a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors e. Depressed reflexes

a. Weakness e. Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

CH. 29 - A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as: a. petechiae. b. erythema. c. ecchymosis. d. telangiectasia.

a. petechiae Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

CH. 20 - The triage nurse at an ambulatory clinic receives a call from a person with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this potential eye injury? a. "Remove any visible metal fragments." b. "Apply a loose dressing over your eyes." c. "Rinse your eyes immediately with water." d. "Keep your eyes open to allow tears to form."

b. "Apply a loose dressing over your eyes." An initial intervention for a penetrating eye injury includes covering the eye(s) with a dry, sterile patch and protective shield. The fragments should not be removed by the person or others. Penetrating eye injuries should not be irrigated (only irrigate for chemical eye injuries).

CH. 64 - A 66-yr-old man with type 2 diabetes and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask? a. "Did you have any hypoglycemic reactions?" b. "Have you noticed any bruising or bleeding?" c. "Have you had any dizzy spells when standing up?" d. "Do you have any numbness or tingling in your feet?"

b. "Have you noticed any bruising or bleeding?" Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

CH. 48 - The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? a. "Smokeless tobacco products decrease the risk of kidney damage." b. "I can help control my blood pressure by avoiding foods high in salt." c. "I should have yearly dilated eye examinations by an ophthalmologist." d. "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."

b. "I can help control my blood pressure by avoiding foods high in salt." Patients with type 2 diabetes to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment of retinopathy.

CH. 48 - The nurse teaches a patient with diabetes about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? a. "I plan to lose 25 pounds this year by following a high-protein diet." b. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." c. "I should include more fiber in my diet than a person who does not have diabetes." d. "If I use an insulin pump, I will not need to limit foods with saturated fat in my diet."

b. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes. High-protein diets are not recommended for weight loss.

CH. 48 - The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement? a. "I should only walk barefoot in nice dry weather." b. "I should look at the condition of my feet every day." c. "I will need to cut back the number of times I shower per week." d. "My shoes should fit nice and tight because they will give me firm support."

b. "I should look at the condition of my feet every day." Patients with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.

CH. 21 - The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? a. "This is often due to an infection that will resolve on its own." b. "Many people experience an age-related decline in their hearing." c. "This is likely an effect of your medications. Try stopping them for a few days." d. "You can accommodate for your hearing loss with a few small changes in your routine."

b. "Many people experience an age-related decline in their hearing." Presbycusis is a loss of hearing that is both common and age-related. Infections are most often accompanied by different symptoms. It would be inappropriate to counsel the patient to stop his medications. It would be simplistic to advise the patient to accommodate the hearing loss rather than seek intervention.

CH. 49 - The nurse receives a phone call from a patient taking cyclophosphamide for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps, weakness, and very little urine output. Which response by the nurse is best? a. "Start taking supplemental potassium, calcium, and magnesium." b. "Stop taking the medication now and call your health care provider." c. "These symptoms will decrease with continued use of the medication." d. "Increase your fluid intake to 3000 mL for 24 hours to improve your urine output."

b. "Stop taking the medication now and call your health care provider." Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL/day. A loop diuretic such as furosemide (Lasix) is used to promote diuresis, and supplements of potassium, calcium, and magnesium may be needed.

CH. 31 - The patient tells the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but there is damage to the right ventricle. What is the best response by the nurse? a. "One coronary vessel curves around and supplies the entire heart muscle." b. "The LAD supplies blood to the left side of the heart and part of the right ventricle." c. "The right ventricle is supplied during systole primarily by the right coronary artery." d. "It is actually on the right side of the heart, but we call it the left anterior descending vessel."

b. "The LAD supplies blood to the left side of the heart and part of the right ventricle." The best response is explaining that the lower portion of the right ventricle receives blood flow from the left anterior descending artery as well as the right coronary artery during diastole.

CH. 20 - When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? a. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." c. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." d. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

b. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time. Primary angle-closure glaucoma is caused by the lens bulging forward and blocking the flow of aqueous humor into the anterior chamber.

CH. 20 - A patient reports intermittent eye dryness. Which question should the nurse ask the patient to determine the etiology of this symptom? a. "Do you use ginkgo to treat asthma symptoms?" b. "What do you take if you have allergy symptoms?" c. "Are you taking propranolol for anxiety disorder?" d. "Are you currently taking prednisone (Deltasone)?"

b. "What do you take if you have allergy symptoms?" Antihistamines or decongestants taken for allergies or colds can cause ocular dryness. Ginkgo biloba is an herbal product and has been used to treat asthma and tinnitus. Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, allergic skin reactions, and increased bleeding. β-Adrenergic blockers can potentiate drugs used to treat glaucoma. Long-term use of prednisone (corticosteroids) may contribute to the development of glaucoma or cataracts.

CH. 21 - The patient has been diagnosed with benign paroxysmal positional vertigo. The nurse knows that which anatomic area of the ear contributes to this disturbance? CAN'T ADD IMAGE a. 1 b. 2 c. 3 d. 4

b. 2 Benign paroxysmal positional vertigo occurs when the organ of balance (the three semicircular canals) have debris or excessive pressure within the lymphatic fluid. The cochlea ("1") is the coiled structure in the inner ear that is the receptor organ for hearing. The auditory canal ("4") and tympanic membrane ("3") have important roles in sound transmission.

CH. 16 - A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline

b. 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action.

CH. 25 - The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? a. 2 minutes b. 5 minutes c. 10 minutes d. 15 minutes

b. 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

CH. 48 - Which patient with type 1 diabetes would be at the highest risk for developing hypoglycemic unawareness? a. A 58-yr-old patient with diabetic retinopathy b. A 73-yr-old patient who takes propranolol (Inderal) c. A 19-yr-old patient who is on the school track team d. A 24-yr-old patient with a hemoglobin A1C of 8.9%

b. A 73-yr-old patient who takes propranolol (Inderal) Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

CH. 21 - When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? a. Swimmer's ear b. Acute otitis media c. Impacted cerumen d. Chronic otitis media

b. Acute otitis media The inability to see the landmarks or light reflex of the tympanic membrane and the bulging and redness of the tympanic membrane are those of acute otitis media. With swimmer's ear and chronic otitis media, there is frequently drainage in the external auditory canal. Impacted cerumen would block the visualization of the tympanic membrane.

CH. 29 - The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What intervention is the priority for this patient after this procedure? a. Position the patient prone. b. Apply a pressure dressing. c. Administer analgesic for pain. d. Return metal objects to the patient.

b. Apply a pressure dressing. The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

CH. 25 - The patient with Parkinson's disease has a pulse oximetry reading of 72% but has no other signs of decreased oxygenation. What is the most likely explanation for the low SpO2 level? a. Anemia b. Artifact c. Dark skin color d. Thick acrylic nails

b. Artifact Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

CH. 55 - The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take? a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Have the patient say "ah" while noting elevation of soft palate. d. Ask the patient to push the tongue to either side against resistance.

b. Ask the patient to shrug the shoulders against resistance. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

CH. 21 - A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks. What should the nurse include in the discharge teaching for this patient? a. Airplane travel will be more comfortable now. b. Avoid sudden head movements or position changes. c. Cough or blow the nose to keep the Eustachian tubes clear. d. Take antihistamines, antiemetics, and sedatives for recovery.

b. Avoid sudden head movements or position changes. After ear surgery, the patient should avoid sudden head movements or position changes. The patient should not cough or blow the nose because this increases pressure in the Eustachian tube and middle ear cavity and may disrupt healing. Airplane travel should be avoided at first as increased pressure and ear popping is normally experienced, which will disrupt healing. Antihistamines, antiemetics, and sedatives are used to decrease the symptoms of acute attacks of Ménière's disease.

CH. 16 - The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply.) a. Apple b. Banana c. Orange juice d. Chocolate milk e. Cooked broccoli

b. Banana c. Orange juice d. Chocolate milk e. Cooked broccoli Milk products, oranges, and bananas are all high in potassium. Cooked broccoli is high in potassium. Apples are low in potassium.

CH. 64 - The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites? a. The best therapy for the acute illness is IV antibiotics. b. Check for an enlarging reddened area with a clear center. c. Surveillance is necessary during the summer months only. d. Antibiotics will prevent Lyme disease if taken for 10 days.

b. Check for an enlarging reddened area with a clear center. After a tick bite, the expanding "bull's eye rash" is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

CH. 49 - The nurse is caring for a patient recently started on levothyroxine for hypothyroidism. What information reported by the patient requires immediate action? a. Weight gain or weight loss b. Chest pain and palpitations c. Muscle weakness and fatigue d. Decreased appetite and constipation

b. Chest pain and palpitations Levothyroxine is used to treat hypothyroidism. With replacement, the patient can be overmedicated, causing hyperthyroidism. Any chest pain, heart palpitations, or heart rate greater than 100 beats/min experienced by a patient starting thyroid replacement should be reported immediately, and electrocardiography and serum cardiac enzyme tests should be performed.

Ch 25 - The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? a. Frequency, family history, hematemesis b. Cough sound, sputum production, pattern c. Weight loss, activity tolerance, orthopnea d. Smoking status, medications, residence location

b. Cough sound, sputum production, pattern The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems but are not as important when dealing with a cough.

CH. 62 - The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? a. Recent knee trauma b. Debilitating joint pain c. Repeated knee infections d. Onset of frozen knee joint

b. Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

CH. 29 - The nurse is providing care for older adults on a subacute, geriatric medical unit. What effect does aging have on hematologic function of older adults? a. Thrombocytosis b. Decreased hemoglobin c. Decreased WBC count d. Decreased blood volume

b. Decreased hemoglobin Older adults often have decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.

CH. 64 - A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan? a. Joint destruction caused by an autoimmune process b. Degeneration of articular cartilage in synovial joints c. Overproduction of synovial fluid resulting in joint destruction d. Breakdown of tissue in non-weight-bearing joints by enzymes

b. Degeneration of articular cartilage in synovial joints OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

CH. 20 - A patient has ptosis resulting from myasthenia gravis. Which assessment finding would the nurse expect? a. Redness and swelling of the conjunctiva b. Drooping of the upper lid margin in one or both eyes c. Redness, swelling, and crusting along the eyelid margins d. Small, superficial white nodules along the eyelid margin

b. Drooping of the upper lid margin in one or both eyes Ptosis is the term used to describe drooping of the upper eyelid margin, which may be either unilateral or bilateral. Ptosis can be a result of mechanical causes, such as an eyelid tumor or excess skin, or from myogenic causes such as myasthenia gravis. Redness, swelling of the conjunctive, or crusting along the eyelid margins may indicate an infection such as viral or bacterial conjunctivitis. Small superficial white nodules along the eyelid margin may indicate hordeolum (sty).

CH. 44 - A patient has sought care because of recent difficulties in establishing and maintaining a urine stream as well as pain that occasionally accompanies urination. How should the nurse document this abnormal assessment finding? a. Anuria b. Dysuria c. Oliguria d. Enuresis

b. Dysuria Painful and difficult urination is characterized as dysuria. Whereas anuria is an absence of urine production, oliguria is diminished urine production. Enuresis is involuntary nocturnal urination.

CH. 20 - When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? a. Giving anticipatory guidance about the loss of central vision that will occur b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss c. Recognizing that eye damage caused by glaucoma can be reversed in the early stages d. Managing the pain patients with glaucoma have that persists until the optic nerve atrophies

b. Encouraging compliance with drug therapy for the glaucoma to prevent vision loss Drug therapy is necessary to prevent the eventual vision loss that may occur as a consequence of glaucoma. For this reason, encourage the patient to remain compliant with drug therapy.

CH. 21 - After an acoustic neuroma is removed from a patient, the nurse teaches the patient about tumor recurrence. What should the nurse instruct the patient to monitor? (Select all that apply.) a. Lack of coordination b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye e. Clear drainage from the nose

b. Episodes of dizziness c. Worsening of hearing d. Inability to close the eye An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

CH. 49 - The patient in the emergency department after a car accident is wearing medical identification listing Addison's disease. What should the nurse expect to be included in the care of this patient? a. Low-sodium diet b. Increased glucocorticoid replacement c. Limiting IV fluid replacement therapy d. Withholding mineralocorticoid replacement

b. Increased glucocorticoid replacement The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may need large volumes of IV fluid replacement and a high-sodium diet. Withholding mineralocorticoid replacement cannot be done for patients with Addison's disease.

CH. 29 - A patient had a splenectomy for injuries sustained in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen? (Select all that apply.) a. Impaired fibrinolysis b. Increased platelet levels c. Increased eosinophil levels d. Fatigue and cold intolerance e. Impaired immunologic function

b. Increased platelet levels e. Impaired immunologic function Splenectomy can result in increased platelet levels and impaired immunologic function because of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.

CH. 31 - The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure? a. Iron b. Iodine c. Aspirin d. Penicillin

b. Iodine The provider will usually use an iodine-based contrast to perform this procedure. Therefore, it is imperative to know whether the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.

CH. 62 - The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? a. 2 × 6 cm right calf abrasion with sanguineous drainage b. Left leg externally rotated and shorter than the right leg c. Stooped posture with a shuffling gait and slow movements d. Mild pain and minimal swelling of the right ankle and foot

b. Left leg externally rotated and shorter than the right leg Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

CH. 62 - A patient underwent amputation below the knee on the left leg after a traumatic accident. Which intervention should the nurse include in the plan of care? a. Sit in a chair for 1 to 2 hours three times each day. b. Lie prone with hip extended for 30 minutes 4 times per day. c. Dangle the residual limb for 20 to 30 minutes every 6 hours. d. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

b. Lie prone with hip extended for 30 minutes 4 times per day. To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

CH. 16 - You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. You should hold a medication from which classification until you consult with the health care provider? a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives

b. Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

CH. 16 - You are admitting a patient who reports abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

CH. 48 - The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? a. Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease. b. Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. c. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes. d. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.

b. Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

CH. 48 - A patient with diabetes is scheduled for a fasting blood glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time? a. 6:00 PM on the evening before the test b. Midnight before the test c. 4:00 AM on the day of the test d. 7:00 AM on the day of the test

b. Midnight before the test Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

CH. 48 - A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? a. Avoid sick people and wash hands. b. Obtain comprehensive dental care. c. Maintain hemoglobin A1C below 7%. d. Coughing and deep breathing with splinting

b. Obtain comprehensive dental care. A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.

CH. 64 - The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient's knees? a. Ulnar drift b. Pain with joint movement c. Reddened, swollen affected joints d. Stiffness that increases with movement

b. Pain with joint movement Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

CH. 16 - You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypoxemia d. Normal acid-base balance with hypercapnia

b. Partially compensated respiratory acidosis A low pH (normal, 7.35 to 7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35 to 45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

CH. 20 - A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? a. Photorefractive keratectomy (PRK) b. Phakic intraocular lenses (phakic IOLs) c. Refractive intraocular lens (refractive IOL) d. Laser-assisted in situ keratomileusis (LASIK)

b. Phakic intraocular lenses (phakic IOLs) Phakic intraocular lenses (phakic IOLs) is the implantation of a contact lens in front of the natural lens. PRK is used with low to moderate amounts of myopia, and the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Refractive IOL is also for patients with a high degree of myopia or hyperopia and involves removing the natural lens and implanting an intraocular lens. LASIK surgery is similar to PRK except that the epithelium is replaced after surgery.

CH. 25 - After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? a. Bronchospasm b. Pneumothorax c. Pulmonary edema d. Respiratory acidosis

b. Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

CH. 29 - A 62-yr-old patient with disseminated intravascular coagulation (DIC) after urosepsis has a platelet count of 48,000/μL. The nurse should assess the patient for which abnormality? a. Pallor b. Purpura c. Pruritus d. Palpitation

b. Purpura The normal range for a platelet count is 150,000 to 400,000/μL. Purpura is caused by decreased platelets or clotting factors, resulting in small hemorrhages into the skin or mucous membranes. Pallor is decreased or absent coloration in the conjunctiva or skin. Pruritus is an intense itching sensation. Palpitation is a sensation of feeling the heart beat, flutter, or pound in the chest.

CH. 16 - Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply.) a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake of 3000 to 4000 mL. e. Any heartburn can be managed with an as needed calcium-containing antacid.

b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake of 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

CH. 55 - The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls? (Select all that apply.) a. Memory deficit b. Sensory deficit c. Motor function deficit d. Cranial and spinal nerves e. Reticular activation system f. Central nervous system changes

b. Sensory deficit c. Motor function deficit f. Central nervous system changes Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.

CH. 49 - The provider was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? a. White blood cell levels and signs of infection b. Serum calcium levels and signs of hypocalcemia c. Hemoglobin, hematocrit, and red blood cell levels d. Level of consciousness and signs of acute delirium

b. Serum calcium levels and signs of hypocalcemia Loss of the parathyroid gland is associated with hypocalcemia. Whereas infection and anemia are not associated with loss of the parathyroid gland, cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

CH. 44 - A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) admitted for pneumonia. What laboratory finding would be consistent with decreased kidney function? Serum uric acid of 5.2 mg/dL Serum creatinine 2.3 of mg/dL Urine specific gravity of 1.040 Blood urea nitrogen (BUN) of 10 mg/dL

b. Serum creatinine 2.3 of mg/dL An expected assessment finding related to decreased kidney function in the aging process is an increased serum creatinine. Other expected assessments include an elevated BUN and inability to concentrate urine (with urine specific gravity fixed at 1.010). Uric acid is used as a screening test for disorders of purine metabolism or kidney disease; values depend on renal function, rate of purine metabolism, and dietary intake of food rich in purines. Normal reference intervals: serum creatinine, 0.6 to 1.3 mg/dL; BUN, 6 to 20 mg/dL; urine specific gravity, 1.003 to 1.030; and serum uric acid, 2.3 to 6.6 mg/dL (female) or 4.4 to 7.6 mg/dL (male).

CH. 44 - The nurse is performing an assessment for a patient and preparing to palpate the kidneys. How should the nurse position the patient for this assessment? a. Prone b. Supine c. Seated at the edge of the bed d. Standing, facing away from the nurse

b. Supine To palpate the right kidney, the patient is positioned supine, and the nurse's left hand is placed behind and supports the patient's right side between the rib cage and the iliac crest. The right flank is elevated with the left hand, and the right hand is used to palpate deeply for the right kidney. The normal-sized left kidney is rarely palpable because the spleen lies directly on top of it.

CH. 21 - When examining the patient's ear with an otoscope, the nurse observes discharge in the canal and the patient reports pain with the examination. What should the nurse next assess the patient for? a. Sebaceous cyst b. Swimmer's ear c. Metabolic disorder d. Serous otitis media

b. Swimmer's ear Swimmer's ear or an infection of the external ear is probably the cause of the discharge and pain. Asking the patient about swimming, ear protection, and exposure to types of water can identify contact with contaminated water. After clearing the discharge, the tympanic membrane can be assessed for otitis media. A sebaceous cyst and metabolic disorders would not cause drainage or discomfort in the external ear canal.

CH. 31 - A patient is being admitted for valve replacement surgery. Which assessment finding is indicative of aortic valve stenosis? a. Pulse deficit b. Systolic murmur c. Distended neck veins d. Splinter hemorrhages

b. Systolic murmur The turbulent blood flow across a diseased valve results in a murmur. Aortic stenosis produces a systolic murmur. A pulse deficit indicates a cardiac dysrhythmia, most commonly atrial fibrillation. Right-sided heart failure may cause distended neck veins. Splinter hemorrhages occur in patients with infective endocarditis.

CH. 31 - While auscultating the patient's heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How should the nurse document what is heard? a. Diastolic murmur b. Third heart sound (S3) c. Fourth heart sound (S4) d. Normal heart sounds (S1, S2)

b. Third heart sound (S3) The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.

CH. 31 - A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is most clearly indicative of a myocardial infarction (MI)? a. CK-MB b. Troponin c. Myoglobin d. C-reactive protein

b. Troponin Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.

CH. 31 - The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate? a. Increased viscosity of the patient's blood b. Turbulent blood flow across a heart valve c. Friction between the heart and the myocardium d. A deficit in conductivity impairs normal contractility

b. Turbulent blood flow across a heart valve Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.

CH. 21 - The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates improvement of the middle ear infection? a. Fenestrations are visible in the tympanic membrane. b. Tympanic membrane is gray, shiny, and translucent. c. Cone of light is not visible on the tympanic membrane. d. Tympanic membrane is blue and bulging with no landmarks.

b. Tympanic membrane is gray, shiny, and translucent. The tympanic membrane (TM) is normally pearly gray, white or pink, shiny, and translucent. Perforation of the TM that has not healed will appear as open areas of the tympanic membrane. The absence of the cone of light indicates a retracted TM. A bulging red or blue eardrum and lack of landmarks indicates a fluid-filled middle ear. The fluid may be pus or blood.

CH. 64 - Which nursing intervention is appropriate for a patient with Sjögren's syndrome? a. Ambulate with assistive devices. b. Use lubricating eyedrops frequently. c. Administer acetaminophen as needed. d. Apply ice or heat compresses to affected areas.

b. Use lubricating eyedrops frequently. Sjögren's syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

CH. 31 - A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan? a. Women are less likely to delay seeking treatment than men. b. Women are more likely to have noncardiac symptoms of heart disease. c. Women are often less ill when presenting for treatment of heart disease. d. Women have more symptoms of heart disease at a younger age than men.

b. Women are more likely to have noncardiac symptoms of heart disease. Women often have atypical angina symptoms and nonpain symptoms. Women experience the onset of heart disease about 10 years later than men. Women are often more ill on presentation and delay longer in seeking care than men.

CH. 25 - The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: a. pain. b. atelectasis. c. pneumonia. d. pleural effusion.

b. atelectasis. After surgery, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

CH. 44 - The nurse prepares a patient for discharge after a cystoscopy. It is most important for the nurse to provide additional information in response to which patient statement? a. "I should drink plenty of fluids to prevent complications." b. "If my urine is cloudy, I should contact my health care provider." c. "Bright red bleeding is normal for a few days after the procedure." d. "Sitz baths and acetaminophen will help to reduce my discomfort."

c. "Bright red bleeding is normal for a few days after the procedure." Bright red bleeding after a cystoscopy is not normal and should be reported immediately. Other complications include urinary retention, bladder infection, and perforation of the bladder. Patients should drink plenty of fluids and expect burning on urination, pink-tinged urine, and urinary frequency. Warm sitz baths, heat, and mild analgesics may be used to relieve discomfort.

CH. 44 - A patient tells the nurse that they are having burning on urination, dysuria, and frequency. What is the best response by the nurse? a. "Drink less fluid so you don't have to void so often." b. "Take some acetaminophen to decrease the discomfort." c. "Come in so we can check a clean-catch urine specimen." d. "Avoid caffeine and spicy food to decrease inflammation."

c. "Come in so we can check a clean-catch urine specimen." The patient's symptoms are typical of a urinary tract infection. To verify this, a clean-catch urine specimen must be obtained for a specimen of urine to culture. Drinking less fluid will not improve the symptoms. Acetaminophen would not decrease the discomfort; an antibiotic would be needed. Avoiding caffeine and spicy food may decrease bladder inflammation but will not affect these symptoms.

CH. 25 - A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? a. "Bibasilar wheezes present on inspiration." b. "Diminished breath sounds in the bases of both lungs." c. "Fine crackles posterior right and left lower lung fields." d. "Expiratory wheezing scattered throughout the lung fields."

c. "Fine crackles posterior right and left lower lung fields." Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.

CH. 20 - The nurse is preparing to administer timolol eyedrops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? a. "I have sinusitis." b. "I have migraine headaches a lot." c. "I have chronic obstructive pulmonary disease." d. "I have a history of chronic urinary tract infections."

c. "I have chronic obstructive pulmonary disease." Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.

CH. 29 - A 36-yr-old patient suspected of having leukemia is scheduled for a bone marrow aspiration. What statement in the patient's health history requires immediate follow-up by the nurse? a. "I had a bad reaction to iodine before and almost died." b. "I am taking an antibiotic to treat a urinary tract infection." c. "I have rheumatoid arthritis and take aspirin for joint pain." d. "I have dialysis for chronic renal failure three times a week."

c. "I have rheumatoid arthritis and take aspirin for joint pain." Complications of bone marrow aspiration are minimal, but there is a possibility of damaging underlying structures, especially if the sternum site is used. Other complications include hemorrhage, particularly if the patient is thrombocytopenic, and infection if the white blood cell count is low. The risk of hemorrhage is increased if the patient takes aspirin because it promotes bleeding by inhibiting platelet aggregation. Contrast dye is not used during a bone marrow aspiration. A bone marrow aspiration is not contraindicated in patients who have chronic renal failure on dialysis or a urinary tract infection on an antibiotic.

CH. 20 - The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? a. "I doubt my other eye will ever be affected." b. "I can expect severe pain after this procedure." c. "I should avoid lifting heavy objects and straining." d. "The procedure will correct my vision immediately."

c. "I should avoid lifting heavy objects and straining." Patients should avoid heavy lifting (more than 20 lb) and straining. A patient with a detached retina is at risk for detachment of the other retina. Patients usually have little to no discomfort after scleral buckling. Severe, persistent pain should be reported immediately to the health care provider. Vision is restored in about 90% of retinal detachments. Vision will not be restored immediately and takes days to weeks to improve.

CH. 64 - When reinforcing health teaching on managing osteoarthritis, which patient statement indicates additional instruction is needed? a. "I can use a cane to relieve the pressure on my back and hip." b. "I should take the Naprosyn as prescribed to help control the pain." c. "I should try to stay standing all day to keep my joints from becoming stiff." d. "A warm shower in the morning will help relieve the stiffness I have when I get up."

c. "I should try to stay standing all day to keep my joints from becoming stiff." Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

CH. 64 - The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? a. "I'll try my best to stay out of the sun this summer." b. "I know that I have a high chance of getting arthritis." c. "I'm hoping surgery will be an option for me in the future." d. "I understand I'm going to be vulnerable to getting infections."

c. "I'm hoping surgery will be an option for me in the future." Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

CH. 25 - A patient has metabolic acidosis secondary to type 1 diabetes. What physiologic response should the nurse expect to assess in the patient? a. Vomiting b. Increased urination c. Decreased heart rate d. Increased respiratory rate

d. Increased respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

CH. 29 - The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic effects of aging? a. "Platelet production increases with age and leads to easy bruising." b. "Anemia is common with aging because iron absorption is impaired." c. "Older adults with infections may have only a mild white blood cell count elevation." d. "Older adults often have poor immune function with a decreased number of lymphocytes."

c. "Older adults with infections may have only a mild white blood cell count elevation." During an infection, the older adult may have only a minimal elevation in the total white blood cell count and may not have a fever. Presentation of infection can initially be nonspecific with disorientation, anorexia, and weakness. Platelets are unaffected by the aging process. However, changes in vascular integrity from aging can manifest as easy bruising. Iron absorption is not impaired in the older patient, but adequate nutritional intake of iron may be decreased. The total white blood cell count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.

CH. 48 - A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? a. "With type 2 diabetes, the body of the pancreas becomes inflamed." b. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." c. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." d. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

c. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.

CH. 48 - The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? a. 8:40 PM to 9:00 PM b. 9:00 PM to 11:30 PM c. 10:30 PM to 1:30 AM d. 12:30 AM to 8:30 AM

c. 10:30 PM to 1:30 AM Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

CH. 25 - The nurse is interpreting a tuberculin skin test (TST) for a patient with end-stage renal disease due to diabetes. Which finding would indicate a positive reaction? a. Acid-fast bacilli cultured at the injection site b. 15-mm area of redness at the TST injection site c. 11-mm area of induration at the TST injection site d. Wheal formed immediately after intradermal injection

c. 11-mm area of induration at the TST injection site An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.

CH. 16 - When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is: a. 500 to 1500 mL. b. 1200 to 2200 mL. c. 2000 to 3000 mL. d. 3000 to 4000 mL.

c. 2000 to 3000 mL. Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

CH. 25 - Which patient has early clinical manifestations of hypoxemia? a. A 48-yr-old patient who is intoxicated and acutely disoriented to time and place. b. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. c. A 72-yr-old patient who has four new premature ventricular contractions per minute. d. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.

c. A 72-yr-old patient who has four new premature ventricular contractions per minute. Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.

CH. 62 - A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) a. Apply ice directly to the skin. b. Apply heat to the ankle every 2 hours. c. Administer antiinflammatory medication. d. Compress ankle using an elastic bandage. e. Rest and elevate the ankle above the heart. f. Perform passive and active range of motion.

c. Administer antiinflammatory medication. d. Compress ankle using an elastic bandage. e. Rest and elevate the ankle above the heart. Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

CH. 25 - A patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? a. Thoracentesis b. Bronchoscopy c. Arterial blood gases d. Pulmonary function tests

c. Arterial blood gases Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.

CH. 55 - How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a. Ask the patient to close their eyes and slowly bring the tips of the index fingers together. b. Ask the patient to close their eyes and identify the presence of a common object on the forearm. c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes their eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

CH. 55 - A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study? a. Assess the patient's immunization history. b. Screen the patient for any metal parts or a pacemaker. c. Assess the patient for allergies to shellfish, iodine, or dyes. d. Assess the patient's need for tranquilizers or antiseizure medications.

c. Assess the patient for allergies to shellfish, iodine, or dyes. Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.

CH. 48 - A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? a. Routine insulin therapy and exercise b. Administer a different antibiotic for the UTI c. Cardiac monitoring to detect potassium changes d. Administer IV fluids rapidly to correct dehydration

c. Cardiac monitoring to detect potassium changes This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

CH. 25 - When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? a. Stridor b. Vesicular c. Coarse crackles d. Bronchovesicular

c. Coarse crackles Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

CH. 49 - What should be included in the interprofessional plan of care for a patient with Cushing disease? a. Lab monitoring for hyperkalemia b. Vital sign monitoring for hypotension c. Counseling related to body image changes d. Diet consultation to determine low protein choices

c. Counseling related to body image changes Elevated corticosteroid levels can cause body changes, including truncal obesity, moon face, and hirsutism in women and gynecomastia in men. Counseling and support should be offered because of the changes in body image. Hypokalemia and hypertension are consistent with Cushing disease. Sodium restriction and potassium supplementation are indicated. High-protein choices are necessary to counteract catabolic processes and assist with wound healing.

CH. 44 - The nurse is caring for an older adult patient taking bumetanide. What age-related changes does the nurse inform the patient may be experienced? a. Benign enlargement of prostatic tissues b. Decreased sensation of bladder capacity c. Decreased function of the loop of Henle d. Less absorption in the Bowman's capsule

c. Decreased function of the loop of Henle Bumetanide (Bumex) is a loop diuretic that acts in the loop of Henle to decrease reabsorption of sodium and chloride. Because the loop of Henle loses function with aging, the excretion of drugs becomes less and less efficient. Thus, the circulating levels of drugs are increased and their effects prolonged. The benign enlargement of prostatic tissue, decreased sensation of bladder capacity, and loss of concentrating ability do not directly affect the action of loop diuretics.

CH. 31 - Which aspect of the heart's action does the QRS complex on the ECG represent? a. Depolarization of the atria b. Repolarization of the ventricles c. Depolarization from atrioventricular (AV) node throughout ventricles d. The length of time it takes for the impulse to travel from the atria to the ventricles

c. Depolarization from atrioventricular (AV) node throughout ventricles The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

CH. 21 - A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? a. Vertigo b. Syncope c. Dizziness d. Nystagmus

c. Dizziness Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

CH. 16 - Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? a. Change the injection cap after the administration of IV medications. b. Use a 5-mL syringe to flush the catheter between medications and after use. c. During removal of the catheter, have the patient perform the Valsalva maneuver. d. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

c. During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.

CH. 48 - A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise the patient to take? a. Eat a piece of pizza. b. Drink some diet pop. c. Eat 15 g of simple carbohydrates. d. Take an extra dose of rapid-acting insulin.

c. Eat 15 g of simple carbohydrates. When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.

CH. 64 - The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure should the nurse recommend to slow progression of the disease? a. Use a wheelchair to avoid walking as much as possible. b. Sit in chairs that cause the hips to be lower than the knees. c. Eat a well-balanced diet to maintain a healthy body weight. d. Use a walker for ambulation to relieve the pressure on the hips.

c. Eat a well-balanced diet to maintain a healthy body weight. Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

CH. 16 - When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial space into the cells c. Fluid movement from the interstitial spaces into the plasma d. Fluid movement from the blood vessels into interstitial spaces

c. Fluid movement from the interstitial spaces into the plasma In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

CH. 21 - When assessing an adult patient's external ear canal and tympanum, what assessment techniques should the nurse use? a. Ask the patient to tip their head toward the nurse. b. Note a pearly gray tympanic membrane as a sign of infection. c. Gently pull the auricle up and backward to straighten the canal. d. Identify a normal light reflex by the appearance of irregular edges.

c. Gently pull the auricle up and backward to straighten the canal. When examining a patient's external ear canal and tympanum, ask the patient to tilt the head toward the opposite shoulder. Grasp and gently pull the auricle up and backward to straighten the canal. A healthy, normal tympanic membrane will appear pearl gray, white, or pink and have a cone-shaped light reflex.

CH. 16 - A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? a. Limit foods high in potassium. b. Calcium gluconate IV piggyback. c. Give a potassium-sparing diuretic daily. d. Administer intravenous insulin and glucose.

c. Give a potassium-sparing diuretic daily. Potassium-sparing diuretics inhibit the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. A potassium-sparing diuretic is contraindicated in a patient with hyperkalemia. Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

CH. 20 - When administering eyedrops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? a. Apply pressure to each eyeball for a few seconds after administration. b. Have the patient close the eyes and move them back and forth several times. c. Have the patient put pressure on the inner canthus of the eye after administration. d. Have the patient try to blink out excess medication immediately after administration.

c. Have the patient put pressure on the inner canthus of the eye after administration. Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. The other options will not minimize systemic effects of the medication.

CH. 55 - The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional problems should the nurse expect in this patient? a. Lack of reflexes b. Endocrine problems c. Higher cognitive function problems d. Respiratory, vasomotor, and cardiac dysfunction

c. Higher cognitive function problems Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

CH. 20 - A patient newly diagnosed with glaucoma asks the nurse what has made the pressure in the eyes so high. Which is the nurse's most accurate response? a. Back pressure from cardiac congestion causes corneal edema. b. Cerebral venous dilation prevents normal interstitial fluid resorption. c. Increased production of aqueous humor or blocked drainage increases pressure. d. Congenital anomalies of the lacrimal gland or duct obstruct the passage of tears.

c. Increased production of aqueous humor or blocked drainage increases pressure. Intraocular pressure is increased in glaucoma as a result of excess aqueous humor production or decreased outflow. Cardiac or cerebral circulation changes do not cause glaucoma. Lacrimal anomalies do not affect aqueous humor production.

CH. 48 - A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? a. Central apnea b. Hypoventilation c. Kussmaul respirations d. Cheyne-Stokes respirations

c. Kussmaul respirations In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

CH. 62 - The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? a. Pain b. Left knee stiffness c. Left knee infection d. Left knee instability

c. Left knee infection The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

CH. 16 - You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Slow the rate to keep vein open until next bag is due at noon. b. Notify the health care provider and complete an incident report. c. Listen to the patient's lung sounds and assess respiratory status. d. Assess the patient's cardiovascular status by checking pulse and blood pressure.

c. Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further orders.

CH. 62 - The nurse is completing discharge teaching with a patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? a. Uses an elevated toilet seat. b. Sits with feet flat on the floor. c. Maintains hip in adduction and internal rotation. d. Verifies need to notify future caregivers about the prosthesis.

c. Maintains hip in adduction and internal rotation. The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

CH. 16 - Which nursing intervention is most appropriate when caring for a patient with dehydration? a. Monitor skin turgor every shift. b. Auscultate lung sounds every 2 hours. c. Monitor daily weight and intake and output. d. Encourage the patient to reduce sodium intake.

c. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.

CH. 21 - Otoscopic examination of the patient's left ear indicates the presence of an exostosis. What does the nurse teach the patient about regarding the growth? a. Surgery b. Electrocochleography c. Monitoring of the growth d. Irrigation of the ear canal

c. Monitoring of the growth An exostosis is a bony growth into the ear canal that normally does not require intervention or correction.

CH. 55 - The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging should the nurse expect to note in older adults? a. Quicker reaction time b. Improved sense of taste c. Orthostatic hypotension d. Hyperactive deep tendon reflexes

c. Orthostatic hypotension Older adults are more likely to have orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score, diminished deep tendon reflexes, and slowed reaction times.

CH. 31 - Which action should the nurse implement with auscultation during a patient's cardiovascular assessment? a. Position the patient supine. b. Ask the patient to hold their breath. c. Palpate the radial pulse while auscultating the apical pulse. d. Use the bell of the stethoscope when auscultating S1 and S2.

c. Palpate the radial pulse while auscultating the apical pulse. To detect a pulse deficit, simultaneously palpate the radial pulse when auscultating the apical area. The diaphragm is more appropriate than the bell when auscultating S1 and S2. A sitting or side-lying position is most appropriate for cardiac auscultation. It is not necessary to ask the patient to hold their breath during cardiac auscultation.

CH. 20 - During a health history, a 43-yr-old teacher reports increasing difficulty reading printed materials for the past year. What change related to aging does the nurse suspect? a. Myopia b. Hyperopia c. Presbyopia d. Astigmatism

c. Presbyopia Presbyopia is a loss of accommodation causing an inability to focus on near objects. This occurs as a normal part of aging process starting around age 40 years. Myopia is nearsightedness (near objects are clear and far objects are blurred). Astigmatism results in visual distortion related to unevenness in the cornea. Hyperopia is farsightedness (near objects are blurred and far objects are clearly seen).

CH. 48 - The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to explain how this medication works? a. Increases insulin production from the pancreas. b. Slows the absorption of carbohydrate in the small intestine. c. Reduces glucose production by the liver and enhances insulin sensitivity. d. Increases insulin release from the pancreas and inhibits glucagon secretion.

c. Reduces glucose production by the liver and enhances insulin sensitivity. Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

CH. 64 - A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern should the nurse recommend? a. Bed rest with bathroom privileges b. Daily high-impact aerobic exercise c. Regular exercise program of walking d. Frequent rest periods with minimal exercise

c. Regular exercise program of walking A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

CH. 16 - When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? a. Polyuria b. Bradycardia c. Restlessness d. Difficulty breathing

c. Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

CH. 16 - You receive a provider's prescription to change a patient's IV from 5% dextrose in 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the rationale for this IV order change? a. Sodium, 136 mEq/L; potassium, 3.6 mEq/L b. Sodium, 145 mEq/L; potassium, 4.8 mEq/L c. Sodium, 135 mEq/L; potassium, 4.5 mEq/L d. Sodium, 144 mEq/L; potassium, 3.7 mEq/L

c. Sodium, 135 mEq/L; potassium, 4.5 mEq/L The normal range for serum sodium is 136 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

CH. 29 - The nurse collects a nutritional history from a 22-yr-old woman who is planning to conceive a child in the next year. Which foods reported by the woman would indicate that her diet is high in folate and iron? a. Crab, fish, and tuna b. Milk, cheese, and yogurt c. Spinach, beans, and liver d. White rice, potatoes, and pasta

c. Spinach, beans, and liver Normal intake of iron and folic acid is necessary for the development of red blood cells, and normal levels before conception and in early pregnancy are particularly important for normal fetal development. Foods high in both folic acid and iron include liver, red meat, egg yolks, turkey or chicken giblets, beans, lentils, chickpeas, soybeans, spinach, and collard greens. In addition, enriched cereals, pasta, and breads are also high in both folic acid and iron (check the labels).

CH. 49 - A patient who smokes reports having significant stress and has some eye problems. On assessment, the nurse notes exophthalmos. What additional abnormal findings should the nurse assess for? a. Muscle weakness and slow movements b. Puffy face, decreased sweating, and dry hair c. Systolic hypertension and increased heart rate d. Decreased appetite, increased thirst, and pallor

c. Systolic hypertension and increased heart rate The manifestations are consistent with Graves' disease or hyperthyroidism. Systolic hypertension, increased heart rate, and increased thirst are associated with hyperthyroidism. Cigarette smoking places the patient at increased risk for Graves' disease. The inhaled cigarette toxins may absorb via the eye orbits, causing exophthalmos. A puffy face; decreased sweating; dry, coarse hair; muscle weakness and slow movements; decreased appetite; and pallor are all manifestations of hypothyroidism.

CH. 55 - The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test? a. The patient will be tilted on a table during the test. b. It is noninvasive, and there is no risk of electric shock. c. The pain that occurs is from the insertion of the needles. d. The passive sensor does not make contact with the patient.

c. The pain that occurs is from the insertion of the needles. With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.

CH. 29 - A blood type and cross-match has been ordered for a patient who has an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains this result? a. The patient can be transfused with type AB blood. b. The patient may only receive a type A transfusion. c. The patient has A antigens on his red blood cells (RBCs). d. Antibodies are present on the surface of the patient's RBCs.

c. The patient has A antigens on his red blood cells (RBCs). A person with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.

CH. 25 - The nurse is palpating the patient's chest during a focused respiratory assessment in the emergency department. Which finding is a medical emergency? a. Increased tactile fremitus b. Diminished chest movement c. Tracheal deviation to the left d. Decreased anteroposterior (AP) diameter

c. Tracheal deviation to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

CH. 20 - A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? a. Initiate coping strategies to reduce stress. b. Identify patient's strengths and support system. c. Verbalize feelings related to visual impairment. d. Transition successfully to the sudden vision loss.

c. Verbalize feelings related to visual impairment. The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.

CH. 62 - A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? a. "You must ambulate with a physical therapist for the first few days." b. "The cast is not dry yet, so it may be damaged while using crutches." c. "Rest, ice, compression, and elevation are in process to decrease pain." d. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

d. "Excess edema and complications are prevented when the leg is elevated for 24 hours." For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. RICE is used for soft tissue injuries, not with long leg casts.

CH. 21 - The nurse is assessing an older adult patient who has just been transferred to the long-term care facility. Which assessment question will best allow the nurse to assess for the presence of presbycusis? a. "Do you ever experience any ringing in your ears?" b. "Have you ever fallen down because you became dizzy?" c. "Do you ever have pain in your ears when you're chewing or swallowing?" d. "Have you noticed any change in your hearing in recent months and years?"

d. "Have you noticed any change in your hearing in recent months and years?" Presbycusis is an age-related change in auditory acuity. Whereas ringing in the ears is termed tinnitus, dizziness and falls are related to balance and the function of the vestibular system. Presbycusis is not associated with pain during chewing and swallowing.

CH. 62 - A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? a. "I probably won't be able to play soccer for 6 to 8 months." b. "They will have me do range of motion with my knee soon after surgery." c. "I will need to wear an immobilizer and progressively bear weight on my knee." d. "I can't wait to get this done now so I can play in the soccer tournament next month."

d. "I can't wait to get this done now so I can play in the soccer tournament next month." The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. A physical therapist will oversee initial range of motion, immobilization, and progressive weight bearing.

CH. 20 - The nurse is teaching a patient about timolol eyedrops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? a. "I may feel some palpitations after instilling these eyedrops." b. "I should withhold this medication if my blood pressure becomes elevated." c. "I should keep my eyes closed for 15 minutes after instilling these eyedrops." d. "I may have some temporary blurring of vision after instilling these eyedrops."

d. "I may have some temporary blurring of vision after instilling these eyedrops." It is common for patients to have a temporary blurring of vision for a few minutes after instilling eyedrops. This should not cause concern to the patient. Because timolol is a β-blocker, heart rate may slow, and blood pressure is more likely to decrease if absorbed systemically.

CH. 64 - The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement? a. "I perform range of motion exercises at least twice a day." b. "I use a heating pad for 20 minutes to reduce morning stiffness." c. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." d. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

d. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)." Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

CH. 55 - A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit because of the surgery? a. Increased heart rate b. Loss of coordination c. Impaired swallowing d. Altered sense of smell

d. Altered sense of smell Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.

CH. 20 - The nurse teaches a patient prescribed dipivefrin eyedrops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? a. "The eyedrops could cause a fast heart rate and high blood pressure." b. "I will need to take the eyedrops twice a day for at least 2 to 3 months." c. "I may have eye discomfort and redness from the use of these eyedrops." d. "I will apply gentle pressure on the inside corner of my eye after each eyedrop."

d. "I will apply gentle pressure on the inside corner of my eye after each eyedrop." To avoid systemic reactions such as tachycardia and hypertension, the patient should apply punctual occlusion after instillation of the eyedrops. Dipivefrin will control chronic open-angle glaucoma but will not cure the disease. Side effects associated with dipivefrin include ocular discomfort and redness, tachycardia, and hypertension.

CH. 48 - The nurse is teaching a patient with type 2 diabetes about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? a. "I will go running when my blood sugar is too high to lower it." b. "I will go fishing frequently and pack a healthy lunch with plenty of water." c. "I do not need to increase my exercise routine since I am on my feet all day at work." d. "I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week."

d. "I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week." The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.

CH. 20 - The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? a. "Prolonged eye irritation is an expected adverse effect of this medication." b. "This medication will help to raise intraocular pressure to a near normal level." c. "This medication needs to be continued for at least 5 years after your initial diagnosis." d. "It is important not to do activities requiring visual acuity immediately after administration."

d. "It is important not to do activities requiring visual acuity immediately after administration." Pilocarpine causes blurred vision and difficulty in focusing, so it is important not to engage in any activities requiring visual acuity until the vision clears. It should not cause prolonged eye irritation, and this should be immediately reported to the prescribing care provider. This medication will decrease intraocular pressure.

CH. 64 - Which statement suggests a need for the nurse to assess the patient for ankylosing spondylitis? a. "My right elbow has become red and swollen over the last few days." b. "I wake up stiff every morning, and my knees just don't want to bend." c. "My husband tells me that my posture has become so stooped this winter." d. "My lower back pain seems to be getting worse and nothing seems to help."

d. "My lower back pain seems to be getting worse and nothing seems to help." AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

CH. 31 - Which instruction by the nurse to a patient who is about to undergo Holter monitoring is accurate? a. "You may remove the monitor only to shower or bathe." b. "You should connect the monitor whenever you feel symptoms." c. "You should refrain from exercising while wearing this monitor." d. "You will need to keep a diary of your activities and symptoms."

d. "You will need to keep a diary of your activities and symptoms." A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

CH. 16 - When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? a. 60 mL in 90 minutes b. 1200 mL in 24 hours c. 300 mL per 8-hour shift d. 20 mL for 2 consecutive hours

d. 20 mL for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

CH. 49 - A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in determining a diagnosis for this patient? a. Administration of β-blocker medications b. Abdominal palpation to search for a tumor c. Administration of potassium-sparing diuretics d. A 24-hour urine collection for fractionated metanephrines

d. A 24-hour urine collection for fractionated metanephrines Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma, an α-adrenergic receptor blocker is used preoperatively to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

CH. 16 - The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? a. A patient with a traumatic brain injury b. A patient with type 1 diabetes mellitus c. A patient with acute respiratory failure d. A patient with nasogastric tube suction

d. A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

CH. 64 - The patient developed acute gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? a. Decrease fluid intake b. Drink a glass of wine daily c. Administration of probenecid d. Administration of allopurinol

d. Administration of allopurinol To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient's aspirin will inactivate its effect, resulting in urate retention. Dietary restrictions that limit alcohol and foods high in purine help minimize uric acid production.

CH. 20 - A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? a. Teach about visual enhancement techniques. b. Assess coping strategies and support systems. c. Teach nutritional strategies to improve vision. d. Assess impact of vision on normal functioning.

d. Assess impact of vision on normal functioning. The most important nursing intervention is to assess the patient's ability to function with the visual impairment. The nurse will use this information to plan nursing care, including assessment of the patient's coping strategies and teaching about vision enhancement techniques and nutrition.

CH. 31 - A patient who has a history of heart failure and chronic obstructive lung disease is admitted with severe dyspnea. Which value would the nurse expect to be elevated if the cause of dyspnea was cardiac related? a. Serum potassium b. Serum homocysteine c. High-density lipoprotein d. B-type natriuretic peptide (BNP)

d. B-type natriuretic peptide (BNP) Elevation of BNP indicates the presence of heart failure. Elevations help to distinguish cardiac versus respiratory causes of dyspnea. Elevated potassium, homocysteine, or HDL levels may indicate increased risk for cardiovascular disorders but do not indicate that cardiac disease is present.

CH. 20 - During the course of a health history to assess vision, a patient reports dry eyes. What should the nurse assess next? a. Assess for contact lenses. b. Suggest saline eyedrops. c. Ask about eyeglass usage. d. Check the medication list.

d. Check the medication list. The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses, but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eyedrops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes.

CH. 25 - After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? a. Decreased response to hypercapnia b. Decreased number of functional alveoli c. Increased calcification of costal cartilage d. Decreased respiratory defense mechanisms

d. Decreased respiratory defense mechanisms Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.

CH. 44 - A patient in the intensive care unit is receiving gentamicin for treatment of pneumonia from Pseudomonas aeruginosa. What assessment results should the nurse report to the health care provider? a. Decreased weight b. Increased appetite c. Increased urinary output d. Elevated creatinine level

d. Elevated creatinine level Gentamicin can be toxic to the kidneys and the auditory system. The elevated creatinine level must be reported to the provider because it probably indicates renal damage. Other factors that may occur with renal damage would include increased weight and decreased urinary output. Many medications have side effects of anorexia.

CH. 62 - The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate? a. Promote vitamin C and calcium intake in the diet. b. Provide passive range of motion to all the joints every 4 hours. c. Keep the left leg in extension and abduction to prevent contractures. d. Encourage isometric quadriceps-setting exercises at least 4 times a day.

d. Encourage isometric quadriceps-setting exercises at least 4 times a day. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

CH. 48 - The nurse caring for a patient hospitalized with diabetes would look for which laboratory test result to obtain information on the patient's past glucose control? a. Prealbumin level b. Urine ketone level c. Fasting glucose level d. Glycosylated hemoglobin level

d. Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

CH. 62 - The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? a. Administer enoxaparin (Lovenox). b. Provide range-of-motion exercises. c. Apply sequential compression boots. d. Immobilize the fracture preoperatively.

d. Immobilize the fracture preoperatively. The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

CH. 29 - When assessing laboratory values on a patient admitted with septicemia, what does the nurse expect to find? a. Increased platelets b. Increased red blood cells c. Decreased erythrocyte sedimentation rate (ESR) d. Increased bands in the white blood cell (WBC) differential

d. Increased bands in the white blood cell (WBC) differential When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Increased red blood cells or decreased ESR is not indicative of septicemia.

CH. 31 - The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? a. Stenosis of the heart valves b. Decreased adrenergic sensitivity c. Increased parasympathetic activity d. Loss of elasticity in arterial vessels

d. Loss of elasticity in arterial vessels An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.

CH. 20 - When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? a. Inner canthus b. Outer canthus c. Center of the eyeball d. Lower conjunctival sac

d. Lower conjunctival sac Ocular medications, such as pilocarpine, should be instilled into the lower conjunctival sac. Never apply eyedrops directly to the cornea. Applying the drops to the inner canthus will cause them to be distributed systemically.

CH. 62 - The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/VN? a. Assess skin integrity around the traction boot. b. Determine correct body alignment to enhance traction. c. Remove weights from traction when turning the patient. d. Monitor pain intensity and administer prescribed analgesics.

d. Monitor pain intensity and administer prescribed analgesics. The LPN/VN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment and should not be delegated or done.

CH. 16 - You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorus falling to 2.1 mg/dL

d. Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs because of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 3.0 to 4.5 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

CH. 25 - A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? a. Thoracentesis b. Pulmonary angiogram c. CT scan of the patient's chest d. Positron emission tomography (PET)

d. Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

CH. 55 - When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding? a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift

d. Pronator drift Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

CH. 31 - Which anatomic feature of the heart directly stimulates ventricular contractions? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

d. Purkinje fibers The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.

CH. 49 - The patient with an adrenal hyperplasia is returning from surgery after an adrenalectomy. The nurse should monitor the patient for what immediate postoperative complication? a. Vomiting b. Infection c. Thromboembolism d. Rapid blood pressure changes

d. Rapid blood pressure changes The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

CH. 55 - A patient with heart failure and type 1 diabetes is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? a. Furosemide 20 mg IV b. Alprazolam 0.5 mg oral c. Ciprofloxacin 500 mg oral d. Regular insulin 6 units subcutaneous

d. Regular insulin 6 units subcutaneous Patients with type 1 diabetes must receive insulin the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).

CH. 31 - What is an appropriate explanation for the nurse to give to a patient about the purpose of intermittent pneumatic compression devices after a surgical procedure? a. The devices keep the legs warm while the patient is not moving much. b. The devices maintain the blood flow to the legs while the patient is on bed rest. c. The devices keep the blood pressure down while the patient is stressed after surgery. d. The devices provide compression of the veins to keep the blood moving back to the heart.

d. The devices provide compression of the veins to keep the blood moving back to the heart. Intermittent pneumatic compression devices provide compression of the veins while the patient is not using skeletal muscles to compress the veins, which keeps the blood moving back to the heart and prevents blood pooling in the legs that could cause deep vein thrombosis. The warmth is not important. Blood flow to the legs is not maintained. Blood pressure is not decreased with the use of intermittent sequential compression stockings.

CH. 44 - When a patient reports acute, severe, renal colic pain in the lower abdomen, the nurse suspects that the patient is most likely to have an obstruction at which area? a. Kidney b. Urethra c. Bladder d. Ureterovesical junction

d. Ureterovesical junction The ureterovesical junction is the narrowest part of the urethra and easily obstructed by urinary calculi. With a stone in the kidney or at the ureteropelvic junction, the pain may be dull costovertebral flank pain. Stones in the bladder do not cause obstruction or symptoms unless they are staghorn stones. The urethra seldom has obstruction related to stones.

CH. 21 - A patient with septic shock is receiving multiple medications. The nurse assesses which intravenous (IV) medication is the most likely to cause a hearing loss? a. Aspirin b. Dopamine c. Ampicillin d. Vancomycin

d. Vancomycin The IV medication in use that is most likely to cause a hearing loss is vancomycin (Vancocin) because it is an ototoxic medication. For that reason, serum drug levels are monitored to maintain therapeutic levels and reduce the risk of ototoxicity. Aspirin can also cause hearing loss, but it is not administered IV. Neither dopamine nor ampicillin is likely to cause hearing loss.

CH. 44 - The nurse obtained a urine specimen from a patient. What result should the nurse recognize as an abnormal finding? a. pH of 6.0 b. Amber yellow color c. Specific gravity of 1.025 d. White blood cells (WBCs) 9/hpf

d. White blood cells (WBCs) 9/hpf Normal WBC levels in urine are below 5/hpf, with levels exceeding this indicative of inflammation or urinary tract infection. A urine pH of 6.0 is average; amber yellow is normal coloration, and the reference range for specific gravity is 1.003 to 1.030.

CH. 16 - You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as: a. metabolic acidosis. b. respiratory acidosis. c. respiratory alkalosis. d. within normal limits.

d. within normal limits. The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.