ATI

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was dysphagia. hoarseness. dyspnea. weight loss.

hoarseness.

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? Impaired sense of humor Loss of depth perception Poor judgment Intellectual impairment

Intellectual impairment

A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements should the nurse include in the teaching? "Most clients do not experience nausea." "Hair loss is common and includes eyebrows and eyelashes." "Most clients start to gain weight during their treatment." "Clients lose their hair, but it usually grows back nice and thick."

"Hair loss is common and includes eyebrows and eyelashes."

A nurse is providing dietary teaching to client who has calcium oxalate kidney stones. Which of the following statements indicates an understanding of the teaching? "I can have almonds as a snack." "I can use soy milk with my cereal." "I may eat a sweet potato for dinner." "I may eat a banana with my breakfast."

"I may eat a banana with my breakfast." Some examples of foods that are highest in oxalates include green leafy vegetables, soy, almonds, potatoes, tea, rhubarb, cereal grains and beets

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching? "I will continue my low-dose aspirin therapy regimen." "I will refrain from eating raw fruits and vegetables." "I will avoid steak and other red meats." "I will continue taking my Coumadin as prescribed."

"I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? "I will eat smaller meals if I feel nauseated." "I will eat foods that are served at room temperature." "I will drink more liquids with my meals." "I will increase the amount of unsaturated fats in my diet."

"I will eat foods that are served at room temperature." The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea.

A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements should the nurse make? "You should avoid drinking liquids an hour before the treatments." "Eating low-calorie foods helps prevent nausea." "Foods that are higher in fat are usually more appealing." "Raw fruits and vegetables will be easier for your body to digest."

"You should avoid drinking liquids an hour before the treatments." Clients should be encouraged to decrease fluid intake just before treatments because fluids may cause nausea and vomiting.

What initial action should the nurse take for a client suspected of experiencing an exacerbation of ulcerative colitis, especially after recent NSAID use?

The nurse should place the client NPO (nothing by mouth) and obtain a prescription for a glucocorticoid.

A nurse is teaching a client who has a new prescription for cyclobenzaprine. Which of the following information should the nurse include in the teaching? Discontinue medication if nausea occurs. Expect urine to turn orange. Monitor for increased muscle spasms. Avoid driving until effects are known.

Avoid driving until effects are known. Cyclobenzaprine can cause drowsiness and dizziness. Instruct the client to avoid driving if these effects occur.

What complications can arise in a client experiencing hypovolemia due to decreased fluid volume?

A client experiencing hypovolemia can suffer from dysrhythmias and orthostatic hypotension due to decreased fluid volume leading to decreased perfusion.

A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A nonhealing sore Bloating Change in bowel pattern Change in moles Nagging cough

A nonhealing sore Change in bowel pattern Change in moles Nagging cough

A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Don sterile gloves. Hyperoxygenate the client. Check the function of the suction catheter. Insert the catheter without suction. Adjust the suction. Apply suction while rotating the catheter. Assess for secretion clearance.

Adjust the suction. Don sterile gloves. Check the function of the suction catheter. Hyperoxygenate the client. Insert the catheter without suction. Apply suction while rotating the catheter. Assess for secretion clearance.

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)

Assess blood glucose level Monitor for an irregular heart rate Weigh the client daily

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Epinephrine Magnesium Atropine Sodium bicarbonate

Atropine

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects? Anorexia and malnutrition Bleeding from the gums Diarrhea and dehydration Full body alopecia

Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets. or bone marrow suppression is defined as a decrease in the ability of the bone marrow to produce blood cells.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? Clamp the catheter. Position the client in left lateral Trendelenburg. Initiate oxygen therapy. Auscultate breath sounds.

Clamp the catheter. The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective? Increased respiratory rate Stable oxygen saturation Clear breath sounds Brisk capillary refill

Clear breath sounds

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.) Decreased platelet count ​Increased hemoglobin count Decreased leukocyte count Increased platelet count Decreased erythrocyte count

Decreased platelet count Decreased leukocyte count Decreased erythrocyte count

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? Different blood pressures in the upper limbs. Different apical and radial pulses. Differences between oral and axillary temperatures. Differences in upper and lower lung sounds.

Different apical and radial pulses. Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading.

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? Headache Dependent edema Polyuria Photosensitivity

Headache

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? Initiate the IV per the parent's request. Notify the provider of the situation. Administer a sedative to calm the client. Offer the client an antiemetic.

Notify the provider of the situation. The nurse should consult with the provider before proceeding. Although the parent must give consent for a minor, the nurse should obtain the minor's assent when the minor is able to give it.

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? Oncology nurse Assistive personnel Senior nursing student Phlebotomist

Oncology nurse

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? Locate the center of the arm between the elbow and the shoulder. Find the center of the anterior aspect of the thigh. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client? Airborne Protective Contact Droplet

Protective Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a stem-cell transplant, require a protective environment.

A nurse is caring for a client who is postoperative following a laryngectomy (voice box). Which of the following actions should the nurse take? Provide humidified air for the client. Position the head of the client's bed in the flat position. Suction the client's mouth toward the surgical side. Clean the client's sutures every 8 hr.

Provide humidified air for the client. The nurse should provide humidification to loosen secretions and prevent crust formation.

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

STANDARD Hepatitis C is a blood-borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids (except sweat), broken skin, and mucous membranes. The nurse should wear additional personal protective equipment if there is possible blood contact or a risk for splashes or sprays of blood or body fluids.

A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take? Humidify the client's room. Serve cooked fruit with meals. Clean dentures in a denture cup. Replace the water in flower vases with fresh water daily.

Serve cooked fruit with meals.

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?

The nurse should recognize that the bleeding is likely due to the adverse effect of the chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia (decreased platelet count) secondary to bone marrow suppression, which can be life-threatening in a client who is receiving chemotherapy.

Why does ulcerative colitis typically result in elevated erythrocyte sedimentation rate (ESR) and WBC count levels?

Ulcerative colitis is an inflammatory disease, which can increase ESR and WBC levels due to inflammation and potential infection.

A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include? Walk outside in the early mornings. Wash the irradiated area following treatment sessions to remove the markings. Vigorously rub the skin dry after bathing. Keep the temperature in the home at least 33° C (91.4° F).

Walk outside in the early mornings. A client who is receiving radiation treatment has special skin care needs due to the drying and irritation that occurs to the skin. The client's skin is especially prone to burning, and he should be encouraged to limit time outdoors in the sun. The nurse should instruct the client to go outside during the early morning or evening to avoid intense sun rays and should encourage the client to stay under awnings, umbrellas, and other forms of shade during the time when the sun's rays are most intense.

ANC below 1k

indicated severe immunosuppression

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? "Tuck your chin when you swallow so you won't choke." "It is no longer possible for you to choke on or aspirate food." "You should have no trouble swallowing fluids." "I will add a thickener to your liquids to prevent aspiration."

"It is no longer possible for you to choke on or aspirate food." The surgical procedure of total laryngectomy provides complete anatomical separation of the trachea and esophagus. Choking and aspiration of food and liquids is no longer possible.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? Hypocalcemia BMI less than 25 Family history Diuretic use

Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation.

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) Hypertension Tremors Moon face Purple striations Buffalo hump

Hypertension Moon face Purple striations Buffalo hump

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care? Check the IV site for bleeding every 8 hr. Limit IM injections. Obtain a rectal temperature every 8 hr. Check the client for proteinuria.

Limit IM injections. The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward.

A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates a need for further teaching? "I will drink liquid beverages through a straw." "I will use dried spices to season my food." "I will rinse my mouth with baking soda and water frequently." "I will eat frozen bananas as a snack."

"I will use dried spices to season my food." The client should avoid spices, acidic foods, and salty foods because they can cause additional irritation to the oral mucosa. Therefore, this statement by the client indicates a need for further teaching.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

"It is caused by the lack of production of aldosterone by the adrenal gland."

A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." "Relax, you'll be asleep for most of the procedure and you won't remember a thing." "I will call your doctor and tell him you still have questions about the procedure." "I can understand because you must be very worried about what the biopsy will show."

"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available? 10% dextrose in water (D10W) 0.45% sodium chloride (0.45% NaCl) Lactated Ringer's solution 5% dextrose in lactated Ringer's solution (D5LR)

10% dextrose in water (D10W) TPN solution has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if there is not another bag of TPN solution available. This will ensure that the client receives the adequate amount of glucose and a solution with the appropriate osmolarity until another TPN solution is available.

A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? Bottled water is an appropriate choice to increase fluid intake. The salad bar is a healthy choice when dining out. Soft-boiled eggs are an appropriate source of protein. Eating at a buffet is a good choice to increase caloric intake.

Bottled water is an appropriate choice to increase fluid intake. Clients who have neutropenia are at risk for foodborne illness. Bottled water prevents client exposure to pathogens that may be found in other water sources.

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

Change the IV tubing every 24h

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day. Take 3,000 mg of vitamin C daily. Restrict calcium intake to one serving per day. Eat 12 oz of animal protein daily.

Drink 3 L of fluid every day.

A nurse is reviewing the provider's history and physical form for a client who has advanced multiple myeloma. Which of the following findings should the nurse expect? Ecchymoses Hypocalcemia Hypotension Polycythemia

Ecchymoses (bruising) A client who has multiple myeloma has an overgrowth of plasma cells in the bone marrow, which leads to a reduction in other types of blood cells. As the platelets are affected, the client is prone to bleeding and bruising.

A nurse is assessing a client who is receiving a parental lipid infusion. Which of the following findings is a manifestation of fat overload syndrome? Elevated temperature Hypertension Peripheral edema Erythema at the insertion site The client is at risk for developing infection and bleeding .

Elevated temperature An elevated temperature is an early manifestation of fat overload syndrome. The client is at risk for coagulopathy and multi-organ system failure due to fat overload syndrome.

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Tachycardia Irritability Tinnitus

Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? Prepare for chest tube insertion. Place the client on his left side in Trendelenburg position. Remove the catheter. Replace the infusion system.

Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? Bradycardia Pulmonary embolism Peripheral vascular disease Hypertension

Pulmonary embolism Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such as shortness of breath, or neurological changes.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? Provide a nonskid mat to alleviate plate movement. Encourage the client to use his right hand when feeding himself. Remind the client to look for food on the left side of the tray. Encourage the use of the wide grip utensils.

Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? Excessive thirst and urination Shakiness and diaphoresis Fever and chills Hypertension and crackles

Shakiness and diaphoresis When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

What are two key laboratory levels a nurse should monitor in a client with ulcerative colitis?

The nurse should monitor the client's erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count levels.

A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? Use a 10-mL syringe to flush the catheter. Flush the lumen with sterile water after each use. Use clean technique when accessing the catheter. Apply firm pressure to the syringe plunger when flushing the lumen.

Use a 10-mL syringe to flush the catheter. During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.

A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching? Limit intake of potassium-rich foods. Restrict sodium intake. Increase carbohydrate intake. Decrease protein intake.

reduce sodium intake The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from "no-added-salt" to table foods to a restriction of 2 g/day.

Why are NSAIDs a concern for clients with ulcerative colitis?

NSAIDs can cause exacerbation of ulcerative colitis, potentially worsening the client's condition.

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A child who has nephrotic syndrome A child recovering from a ruptured appendix A child who has rheumatic fever A child who has cystic fibrosis

A child who has nephrotic syndrome A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia. A child recovering from a ruptured appendix A child who has leukemia is at risk for infection. A client recovering from a ruptured appendix can be infectious. A child who has rheumatic fever A child who has leukemia is at risk for infection. A child who has rheumatic fever can still be infectious from the original causative organism. A child who has cystic fibrosis A child who has leukemia is at risk for infection. A client who has cystic fibrosis is likely to be infectious.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A reddened area over the sacrum Stiffness in the lower extremities Difficulty moving the upper extremities Difficulty hearing some types of sounds

A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take? Obtain the telephone number of the client's provider. Find a location for the client to sit. Call emergency services. Drive the client to the nearest emergency department.

Call emergency services.

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? Leave the client 5 min after beginning the transfusion. Infuse the transfusion at a rate of 200 mL/hr. Check the client's vital signs every hour during the transfusion. Flush the blood tubing with dextrose 5% in water.

Check the client's vital signs every hour during the transfusion.

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Continous bubbling in the water-seal chamber Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.

A nurse is teaching a client who has kidney stones. Which of the following instructions should the nurse include?

Filter your urine everyday The client should filter their urine each day to identify the type of kidney stone.

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? Review laboratory test results for low hemoglobin. Observe for signs of infection. Monitor the mouth for signs of xerostomia. Examine the skin for generalized urticaria.

Observe for signs of infection. Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.

A nurse is preparing a client for placement of a catheter for total parenteral nutrition. Which of the following access sites should the nurse plan to prepare for catheter insertion? Left antecubital vein Right subclavian vein Right femoral artery Left arm radial artery

Right subclavian vein

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Continue to monitor the client as this is an expected finding. Add more water to the suction control chamber of the drainage system. Verify that the suction regulator is on and check the tubing for leaks. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

Verify that the suction regulator is on and check the tubing for leaks.

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

Weigh the client daily Addison's disease is an endocrine disorder that causes weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin. Obtaining the client's daily weight will alert the nurse that dehydration is developing, which could indicate an impending crisis.

A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? Recap the needle. Place the cap on the bedside table and slide the needle into the cap. Wrap the needle with gauze. Dispose of the needle uncapped.

Dispose of the needle uncapped.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? Defibrillation Elective cardioversion CPR Radiofrequency catheter ablation The client is at risk for developing infection and bleeding .

Elective cardioversion Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment.

Why is it important to monitor both the blood pressure and heart rate of a client experiencing hypovolemia?

Monitoring the blood pressure and heart rate is important in clients with hypovolemia to detect and manage potential dysrhythmias and orthostatic hypotension.

What initial action should the nurse take when a post-transplant client shows signs of hypovolemia, such as increased heart rate and decreased blood pressure?

The nurse should lower the head of the client's bed and obtain a prescription to administer an IV bolus.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

The nurse should perform tracheostomy care every 4 hr to reduce the risk of infection.

A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective? Hct 43% WBC 8,000/uL Albumin 4.2 g/dL Calcium 9.4 mg/dL

Albumin 4.2 g/dL Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein. Others: Hct 43% An Hct of 43% is within the expected reference range, but this does not indicate the TPN therapy is effective. Clients with cancer are likely to have a low Hct due to anemia. WBC 8,000/uL A WBC count of 8,000/uL is within the expected reference range, but this does not indicate the TPN therapy is effective. Clients receiving TPN are at risk for developing infection. Calcium 9.4 mg/dL A calcium level of 9.4 mg/dL is within the expected reference range, but this does not indicate the TPN therapy is effective. Clients receiving TPN are at high risk for developing hypercalcemia.

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? Constant bubbling in the suction-control chamber Continuous bubbling in the water-seal chamber Bloody drainage in the collection chamber Fluid-level fluctuations in the water-seal chamber

Continuous bubbling in the water-seal chamber Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? Difficulty reading Inability to recognize his family members Right hemiparesis Aphasia

Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is reviewing the medical record of a client who has acute leukemia. Diagnostic Results Month One: WBC count 15,500/mm3 (5,000 to 10,000/mm3) RBC count 4.3 million/mm3 (4.2 to 5.4 million/mm3) Hemoglobin 15 g/dL (12 to 16 g/dL) Hematocrit 45% (37% to 47%) Platelet count 160,000/mm3 (150,000 to 400,000/mm3) PT 11.5 seconds (11 to 12.5 seconds) INR 1 second (0.8 to 1.1 seconds) PTT 65 seconds (60 to 70 seconds) Sodium 139 mEq/L (136 to 145 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Glucose 100 mg/dL (74 to 106 mg/dL) BUN 16 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Vitamin D 65 ng/dL (25 to 80 ng/dL) The client is at risk for developing what? pt. 1

Infection and bleeding

Month Three: WBC count 15,500/mm3 (5,000 to 10,000/mm3) RBC count 4.0 million/mm3 (4.2 to 5.4 million/mm3) Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 33% (37% to 47%) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) PT 13.5 seconds (11 to 12.5 seconds) INR 2.2 seconds (0.8 to 1.1 seconds) PTT 85 seconds (60 to 70 seconds) Sodium 137 mEq/L (136 to 145 mEq/L) Potassium 4.5 mEq/L (3.5 to 5 mEq/L) Glucose 98 mg/dL (74 to 106 mg/dL) BUN 15 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Vitamin D 65 ng/dL (25 to 80 ng/dL) (pt. 2)

Infection and bleeding

A nurse is assessing four clients on a medical unit. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism? A client who has a butterfly rash on his face. Moon face A client who has a positive Chvostek's sign. A client who has muscle hypertrophy.

Moon face A client who has a butterfly rash on his face. A butterfly rash on the face is a manifestation of lupus erythematosus. A client who has a positive Chvostek's sign. A positive Chvostek's sign is a manifestation of hypocalcemia. A client who has muscle hypertrophy. Muscle atrophy is a manifestation hypercortisolism.

A nurse is caring for a client who is immunocompromised following an allogenic hematopoietic stem cell transplant. The nurse should place the client on which of the following precautions? Protective Droplet Contact Airborne

Protective The nurse should place the client who is immunocompromised on protective isolation. The client should be placed in a room that has positive airflow with HEPA filtration. The nurse should wear a mask, gown, and gloves when caring for the client to protect the client from injury.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care? Use aseptic technique. Clean the inner cannula with mild soap and water. Secure new tracheostomy ties before removing old ones. Apply suction when inserting the catheter.

Secure new tracheostomy ties before removing old ones. Tube dislodgement and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying new ties, the nurse can secure the tube and prevent dislodgement.

A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed? Prone On the nonoperative side Sims' Semi-Fowler's

Semi-Fowler's Pneumonectomy is the surgical removal of the lung, which is most commonly performed to remove a tumor in a client who has lung cancer. Following extubation from the ventilator, the client should be placed in semi-Fowler's position to help to ensure adequate ventilation and decrease the risk of complications. This position also offers the client the most comfort.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? Suction two to three times with a 60-second pause between passes. Perform chest physiotherapy prior to suctioning. Lubricate the suction catheter tip with sterile saline. Hyperventilate the client on 100% oxygen prior to suctioning.

Suction two to three times with a 60-second pause between passes.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? Place the chest tube drainage system above the level of the client's heart. Strip the client's chest tube every 2 hrs. Loop the tubing of the chest tube on the client's bed Tape the connections on the client's chest tube.

Tape the connections on the client's chest tube. The connections on the chest tube should be securely taped to reduce the risk of disconnection which can cause air to enter the client's pleural cavity.

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?

Teach the parents about cortisol replacement therapy The nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

The QT interval reflects the time it takes for ventricular depolarization and repolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? The client's ECG tracing shows irregular heart rate without P waves. The client has an aPTT of 80 seconds. The client experiences sudden weakness of one arm and leg. The client's urine output is cloudy and odorous.

The client experiences sudden weakness of one arm and leg. Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.

A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client? WBC 1,400/mm3 RBC 4.3 x 10¹² /L Hgb 12.1 g/dL Hct 36.5% Platelets 170,000/mm3 Albumin 4.5 g/dL The client has an increased risk for bleeding. The client should receive a diet with increased protein. The client has an increased risk of infection. The client should receive an erythropoiesis stimulating agent.

The client has an increased risk of infection. The low white blood cell count (expected range is 5,000 - 10,000/mm³) places the client at increased risk for infection. The nurse should assess the client's skin and mucous membranes, lung sounds, and venous access sites every 8 hr for signs of infection.

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? To convert atrial fibrillation to sinus rhythm To dissolve clots in the bloodstream To slow the response of the ventricles to the fast atrial impulses To reduce the risk of stroke in clients who have atrial fibrillation

To reduce the risk of stroke in clients who have atrial fibrillation Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation.

A nurse is planning care for a preschooler. Diagnostic Results White blood cell count: 2,000/mm³ (5,000 to 10,000/mm³) Absolute neutrophil count: 1,000/mm³ (less than 1,000/mm³) Hemoglobin: 11 g/dL (9.5 to 14 g/dL) Platelets: 120,000/mm³ (150,000 to 400,000/mm³) Vital Signs Temperature: 37.8° C (100° F) Heart rate:110/min Respiratory rate: 22/min Blood Pressure: 96/51 mm Hg Medical History Child is a 4-year-old male preschooler was diagnosed with Acute Lymphoblastic Leukemia (ALL) with standard risk last week and is in the induction phase of therapy. Chemotherapy with vincristine and doxorubicin was initiated (last therapy received 3 days ago. The child is current with immunizations. The child has an intolerance to lactose and has no known medical allergies. Which of the following potential issues should the nurse identify that the child is at risk for developing? (Select all that apply.)

Tumor lysis syndrome Children with ALL are at risk for developing tumor lysis syndrome because of chemotherapy. It is a condition that occurs during therapy that results in the release of intracellular metabolic during the lysis of malignant cells. Peripheral neuropathy A common side effect of vincristine is peripheral neuropathy. Alopecia Alopecia or hair loss is a common adverse effect of chemotherapy with vincristine and doxorubicin. Hemorrhage Children with ALL are at risk for spontaneous hemorrhage during treatment.

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? Bounding pulsations Irregular pulsations Tachycardia Bradycardia

Irregular pulsations PVCs are early ventricular depolarizations with a pause immediately afterwards. That pause in the usual heart rhythm results in an irregular force and rate on palpation of a peripheral pulse and an irregular beat on auscultation of the apical pulse. PVCs have a wide variety of causes. Clients typically perceive them as "palpitations" and can feel lightheaded if they occur frequently.

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? Clamp the tube when the client is ambulating. Keep the collection device below the level of the client's chest. Coil the tubes carefully to prevent kinking. Lay the client flat to avoid leaks in the tubing.

Keep the collection device below the level of the client's chest.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Clamp the chest tube prior to transferring the client to a wheelchair. Disconnect the chest tube from the drainage system during transport. Keep the drainage system below the level of the client's chest at all times. Empty the collection chamber prior to transport.

Keep the drainage system below the level of the client's chest at all times.

A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client? Remove the parenteral nutrition solution from the refrigerator 2 hr before infusion. Remove unused parenteral nutrition after 12 hr of use. Monitor daily laboratory values and report as needed. Monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it falls behind.

Monitor daily laboratory values and report as needed.

Why is it important for a nurse to monitor a client's urinary output following a renal transplant?

Monitoring urinary output is crucial because excessive urinary output can lead to hypovolemia, characterized by increased heart rate, decreased blood pressure, and concentrated urine.

A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary? An excess amount of doxorubicin can lead to myelosuppression. Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation. An excess amount of doxorubicin can lead to cardiomyopathy. Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.

An excess amount of doxorubicin can lead to cardiomyopathy. Doxorubicin is an antineoplastic antibiotic used in the treatment of various cancers. Irreversible cardiomyopathy with congestive heart failure can result from repeated doses of doxorubicin, and prolonged use can also cause severe heart damage, even years after the client has stopped taking it. The maximum cumulative dose a client should receive is 550 mg/m2 or 450 mg/m2 with a history of radiation to the mediastinum.

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy?

Hyperglycemia TPN is prescribed when extensive nutritional support for prolonged periods of time is required. It is delivered through a central venous access device, usually via the internal jugular or subclavian vein. TPN contains a high concentration of dextrose, which can result in hyperglycemia. Frequent glucose monitoring should be implemented in clients receiving TPN.

A nurse is caring for a client who has experienced a stroke and exhibits parkinsonian effects. The client's cognition fluctuates. Which of the following types of dementia should the nurse expect the client to have? Lewy body disease HIV infection Frontotemporal lobar degeneration Prion disease

Lewy body disease The nurse should expect the client to have Lewy body disease dementia. Clients who have Lewy body disease dementia often experience a stroke and exhibit parkinsonian effects along with fluctuating cognition.

What are some common manifestations of hypovolemia in clients following a transplant?

Manifestations of hypovolemia include increased heart rate, decreased blood pressure, weak peripheral pulses, increased respiratory rate, dry mucous membranes, changes in cognition, and concentrated urine.

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

Sit the client upright Fluid overload can cause dyspnea. The nurse should slow the infusion rate and sit the client upright to help prevent or treat dyspnea. The nurse should also administer oxygen if necessary.

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.