ATI ASSESSMENT B MED/SURG II (YAMILE)

A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.) Dark skin Under 40 years of age Overexposure to ultraviolet light Previous skin injury Genetic predisposition

Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Previous skin injury is correct. Previous skin injury that resulted in a scar is a risk factor for developing skin cancer. Genetic predisposition is correct. Genetic predisposition is a risk factor for developing skin cancer.

A nurse is caring for a 64-year-old client who has a small bowel obstruction. Medical History The client is complaining of cramping abdominal pain, vomiting, and is passing blood and mucus without fecal matter present. History: Hysterectomy 2010 and Crohn's disease since 2013 The client denies continuous pain and states that it is midabdominal and not lower abdominal. Medications: Stelara 90 mg subcutaneous every 8 weeks. Vital Signs Temperature 38.3° C (101° F) Apical pulse 120/min Respiratory rate 20/min Blood pressure 90/54 mm Hg Pulse oximetry 93% on room air Nurses' Notes 0800: Alert and oriented x 3Reports pain in midabdominal regionAbdominal distention noted upon inspection. Tenderness noted on palpation. Hyperactive bowel sounds auscultated.Rates pain as an 8 on a scale of 0 to 10Skin pale and cool Heart tones S1S2 auscultated. Bilateral breath sounds clear. Diagnostic Results CBC:RBC 4.9 million/mm3 (4.7 to 6.1 million/mm3)WBC 12,000 mm3 (5,000 to 10,000 mm3)Hemoglobin 16 g/dL (14 to 18 g/dL)Hematocrit 48% (42% to 52%)Platelets 200,000/mm3 (150,000 to 400,000/mm3) Basic Metabolic Profile:BUN 45 mg/dL (10 to 20 mg/dL)Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)Carbon Dioxide 27 mEq/L (23 to 30 mEq/L)Chloride 10 mEq/L (98 to 106 mEq/L)Glucose 80 mg/dL (74 to 106 mg/dL)Potassium 5.1 mEq/L (3.5 to 5 mEq/L)Sodium 150 mEq/L 136 to 145 mEq/L CT scan: CT scan shows marked distention of the small bowel with dilation of the small bowel loops FLAG A nurse is caring for a 64-year-old client who has a small bowel obstruction. Medical History Vital Signs Nurses' Notes Diagnostic Results Diagnostic Results CBC:RBC 4.9 million/mm3 (4.7 to 6.1 million/mm3)WBC 12,000 mm3 (5,000 to 10,000 mm3)Hemoglobin 16 g/dL (14 to 18 g/dL)Hematocrit 48% (42% to 52%)Platelets 200,000/mm3 (150,000 to 400,000/mm3) Basic Metabolic Profile:BUN 45 mg/dL (10 to 20 mg/dL)Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL)Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL)Carbon Dioxide 27 mEq/L (23 to 30 mEq/L)Chloride 10 mEq/L (98 to 106 mEq/L)Glucose 80 mg/dL (74 to 106 mg/dL)Potassium 5.1 mEq/L (3.5 to 5 mEq/L)Sodium 150 mEq/L 136 to 145 mEq/L CT scan: CT scan shows marked distention of the small bowel with dilation of the small bowel loops For each potential prescription from the provider, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Order Anticipated Nonessential Contraindicated Oxygen 2 L per nasal cannula NG tube Chest x-ray on admission Morphine 4 mg IV PRN pain every 2 hr 0.9% sodium chloride at 150 mL/hr 2,000 mg sodium diet

Oxygen 2 L per nasal cannula is nonessential. Unless the client's oxygenation is compromised, oxygen therapy is not required. Salem Sump NG tube is anticipated. A NG tube is inserted and connected to low continuous suction to decompress the bowel. Chest x-ray on admission is nonessential. Once the NG tube is placed if the tube becomes displaced and the tube requires repositioning an abdominal x-ray will be obtained. Morphine 4 mg IV PRN pain every 2 hr is contraindicated. Opioid analgesics can slow intestinal motility, which can cause vomiting. 0.9% sodium chloride at 150 mL/hr is anticipated. Isotonic solutions are ordered because the client with a small bowel obstruction is placed on an NPO status and is losing fluid and electrolytes through the nasogastric suctioning. 2000 mg gm sodium diet is contraindicated. The client who has a small bowel obstruction should not have anything by mouth due to the obstruction and an NG tube connected to suction is placed to decompress the bowel until the obstruction is resolved.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed.

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? Propranolol Theophylline Montelukast Prednisone

Propranolol Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Severe headache Bradycardia Blurred vision Oriented to person, place, and year

Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.

A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings? The client is experiencing premature atrial contractions. The client has a decreased oxygen saturation level. The client has bilateral wheezes. The client has lower leg edema.

The client is experiencing premature atrial contractions. Pulse pressure devices require the presence of optimal arterial waveforms in order to capture accurate data. Therefore, a dysrhythmia, such as premature atrial contractions, will compromise the readings.

A nurse is caring for a 33-year-old client on a medical-surgical unit. Exhibit 1 Medical History 33-year-old client admitted through the emergency department with lower abdominal pain and multiple bloody, watery stools every day for the last week. States pain is decreased after having a bowel movement. Unable to leave home due to number of stools and urgent need to defecate at times leading to stool incontinence. Client states they had a similar episode two months ago. Recently sprained ankle after stepping down off ladder. Has been taking NSAIDs up until 4 days ago. Client has history of appendectomy as a child. Vital Signs Temperature 37.6° C (99.8° F) Heart rate 110/min Respiration rate 18/min BP 100/68 mm Hg Oxygen saturation 96% on room air Nurses' Notes Alert and oriented x3. Skin warm, dry, and pale relative to genetic background. Heart sounds regular. Lungs clear to auscultation throughout. Abdomen soft, flat. Client reports abdominal pain in lower quadrants. Rates pain as 7 on a scale of 0 to 10. Bowel sounds hyperactive x4. No peripheral edema noted. The nurse is reviewing the client's data to initiate a plan of care for the client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take 1 Actions to Take 2 Potential Condition Parameters to Monitor 1 Parameters to Monitor 2 Actions to Take Potential Condition Parameters to Monitor

The nurse should place the client NPO and obtain a prescription for a glucocorticoid because the client is most likely experiencing ulcerative colitis. The client has recently taken NSAIDs, which can cause exacerbation of the disease. The nurse should monitor the client's erythrocyte sedimentation rate (ESR) and WBC count levels. Ulcerative colitis is an inflammatory disease which increase these laboratory levels due to inflammation and infection.

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance twice a day. daily at bedtime. when the bag is 2/3 full. when the bag is full.

when the bag is 2/3 full. An ileal conduit is used to divert urine outside of the body when the urinary bladder has been removed. The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously, and an appliance must be worn as a collecting device. The bag should be emptied when it becomes 2/3 full to prevent leakage, skin irritation, and infection.

A nurse is preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should plan to include which of the following findings as a manifestation of SLE? Hypothermia Muscle hyperreflexia Weight gain A raised rash

A raised rash A dry, raised rash (butterfly rash) on the face or on sun exposed areas of the body is a manifestation of SLE.

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? Place the client in a supine position postoperatively. Encourage ambulation once fully awake. Offer the client ice cream postoperatively. Instruct the client not to lift over 4.5 kg (10 lb).

Encourage ambulation once fully awake. The nurse should encourage ambulation once the client is fully awake to promote absorption of the carbon dioxide used during the laparoscopy. This minimizes the client's discomfort. The nurse should check the client for nausea before ambulating, and administer an anti-emetic medication if necessary.

A nurse is planning care for a client who has deep-vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care? Apply cold compresses to the affected extremity. Massage the affected extremity. Apply graduated compression stockings at bedtime. Encourage the client to walk.

Encourage the client to walk. The client should avoid sitting or standing for long periods of time. After the client begins anticoagulant therapy, the nurse should encourage the client to walk.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Perform range-of-motion exercises Place suction equipment at the bedside Encourage the use of an incentive spirometer Administer an expectorant

Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

A charge nurse is teaching a group of nurses about agonists and antagonists. The nurse should include in the teaching that which of the following agonist medications binds to receptors and causes activation that affects the cardiovascular system? Insulin Epinephrine Morphine Norethindrone

Epinephrine The nurse should include that epinephrine is an agonist that activates the receptors that affect the cardiovascular system in clients who are at risk for cardiac collapse.

A nurse is obtaining a medical history from a client who is to start warfarin therapy and currently uses herbal supplements at home. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin? Feverfew Black cohosh Echinacea Flaxseed

Feverfew The nurse should instruct the client to avoid taking feverfew while taking warfarin because it will increase the anticoagulant effect.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? Atelectasis Flail chest Hemothorax Pneumothorax

Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? Assess for hypoglycemia 4 hr after the insulin injection. Inject the insulin 15 min before a meal. Monitor for polyuria. Administer with short-acting insulin.

Inject the insulin 15 min before a meal. The nurse should administer lispro insulin 15 min before a meal, because lispro insulin is rapid-acting insulin that has an onset within 15 to 30 min. The client may develop hypoglycemia quickly if they do not eat.

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? "These organs support immunity." "These organs are used in digestion." "These organs regulate electrolyte balance." "These organs assist vitamin absorption."

"These organs support immunity." The nurse should inform the client that the function of the thymus, spleen, and lymph nodes is to support immunity and fight infection.

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? "Place the tablet under your tongue, and then take a small sip of water." "The medication can take up to 15 minutes to take effect." "Avoid taking the medication prior to exercising." "Stop taking the medication and notify your provider if you develop a headache."

"Place the tablet under your tongue, and then take a small sip of water." A client who takes a sublingual medication should place it under his tongue. A sip of water can help the medication dissolve.

A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions? Dehydration Fungal infection Compartment syndrome Pleural effusion

Fungal infection The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction.

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? Hypothermia Protruding eyeballs Elevated blood pressure Furrows in the tongue

Furrows in the tongue In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure? A sternal incision A chest tube Moderate pain Pulmonary function studies

A chest tube A lobectomy is major surgery that involves a large posterolateral or anterolateral incision into bone, muscle, and cartilage. Chest tubes are placed to drain air and fluid and remain in place for several days postoperatively.

A nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. Which of the following laboratory values should the nurse report to the provider before initiating the medication? Sodium 140 mEq/L Potassium 4.5 mEq/L BUN 55 mg/dL Glucose 120 mg/dL

BUN 55 mg/dL This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory value to the provider before initiating the medication.

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following? 2 hr 6 hr 8 hr 4 hr

4 hr The nurse should infuse the packed RBCs for no longer than 4 hr due to temperature inconsistencies that develop over time and the possibility of bacterial contamination.

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? Glucocorticoid medications Dextrose 5% in 0.45% sodium chloride Oral hypoglycemic medications 0.9% sodium chloride IV bolus

0.9% sodium chloride IV bolus The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs.

A nurse is teaching a client who has benign prostatic hypertrophy and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching? "Avoid drinking grapefruit juice when taking this medication." "Expect to see a response from the medication within one week." "Decreased libido is an adverse effect of the medication." "PSA levels will increase while taking this medication."

"Decreased libido is an adverse effect of the medication." The nurse should include in the teaching that the client may experience decreased libido as an adverse effect of the medication because of the androgenic effect on the prostate.

A nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching? "Fibromyalgia causes joint inflammation." "Fibromyalgia may cause me to feel chest pain." "Fibromyalgia commonly causes migraine headaches." "Fibromyalgia symptoms may worsen depending upon the weather

"Fibromyalgia causes joint inflammation." Clients who have fibromyalgia may report joint discomfort. However, fibromyalgia is a noninflammatory disorder and does not cause joint inflammation.

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching? "I plan to use nicotine gum to help me quit smoking." "I am going to take a stress management class." "I will limit myself to only two cups of coffee in the morning." "I should not drive in the winter months."

"I am going to take a stress management class." The nurse should instruct the client that stress can elicit attacks. The client should learn to avoid stressful situations when possible and learn to manage stress to limit the occurrence of attacks.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? Maintain occlusive dressings on the lesions throughout the day and remove them at bedtime. Eliminate the use of products containing salicylic acid. Avoid friction over scaly lesions while bathing. Identify effective stress reduction techniques.

Identify effective stress reduction techniques. Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform? Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis. Maintain constant observation while the balloons are inflated. Suction the tube every 2 hr and as needed to maintain patency. Keep the head of the bed flat at all times to prevent the development of shock.

Maintain constant observation while the balloons are inflated. A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.

A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications? Acetaminophen Celecoxib Cyclobenzaprine Ibuprofen

Acetaminophen According to the American Pain Society, acetaminophen is the primary drug of choice for treating osteoarthritis. The provider would likely begin with this medication.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Nausea Dysphagia Agitation Hypotension

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Kussmaul respirations Apneustic respirations Cheyne-Stokes respirations Stridor

Cheyne-Stokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions? Malnutrition Hepatitis A Diabetes Cirrhosis

Cirrhosis The nurse should recognizes this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition? Anorexia Knuckle deformity Low-grade fever Weight loss

Knuckle deformity Joint deformity is a late manifestation of RA.

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation? Negligence Libel Battery Slander

Negligence The nurse's conduct displays negligence, which is providing client care below the standard of care and placing the clients at risk for harm.

A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following information should the nurse include in the plan? (Select all that apply). Obtain a urine specimen prior to the procedure. Obtain written, informed consent. Administer diphenhydramine (Benadryl) prior to the procedure. Maintain NPO status prior to the procedure. Obtain coagulation studies.

Obtain a urine specimen prior to the procedure is correct. A urine specimen should be obtained prior to the procedure to allow for post-procedure comparison. Obtain written, informed consent is correct. Because the procedure is invasive it requires written, informed consent. Maintain NPO status prior to the procedure is correct. Clients are often prescribed NPO status for six to eight hours prior to the procedure. Obtain coagulation studies is correct. Coagulation studies are obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site as a potential complication.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG. Administer enteric-coated acetaminophen. Administer ibuprofen. Maintain oxygen saturations greater than or equal to 92%.

Obtain an EKG. The nurse should obtain an EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend? Carrots Raisins Maple syrup Orange juice

Raisins Foods high in iron are recommended to improve a low hemoglobin level. Raisins are a high source of iron.

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include? Keep both eyes patched. Restrict head movement. Eye drops to constrict the pupils will be prescribed. Apply cool compresses.

Restrict head movement. The client should restrict head and eye movement to prevent further detachment prior to surgery.

A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ___________mL

STEP 1: What is the unit of measurement to calculate? mL STEP 2: Set up an equation and solve for X. 1 oz/30 mL = 4 oz/X mL X = 120 mL STEP 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. STEP 1: What is the unit of measurement to calculate? mL STEP 2: Set up an equation and solve for X. 1 oz/30 mL = 12 oz/X mL X = 360 mL STEP 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 12 oz = 360 mL.

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? Kernig's sign Nuchal rigidity Brudzinski's sign Bradykinesia

Brudzinski's sign This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.

A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan? Instruct the client to deep breathe every 4 hr. Check the client's voice every 2 hr. Place the head of the client's bed in the flat position. Hyperextend the client's neck.

Check the client's voice every 2 hr. The nurse should assess the client's voice every 2 hr to monitor for hoarseness, which is a manifestation of laryngeal nerve damage.

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? Teach the client about his diagnosis. Provide a schedule of visiting hours to the client's family. Document the client's allergies in the electronic medical record. Develop a plan of care for the client.

Document the client's allergies in the electronic medical record. The greatest risk to this client is injury from incomplete or inaccurate documentation. Therefore, the first action the nurse should take is to document the assessment findings in the client's medical record. This will allow for continuity of care and reduces the risk for injury due to inaccurate documentation.

A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? Blood in the IV tubing Absence of blanching at the insertion site Edema in the palm of the hand Warmth around the insertion site

Edema in the palm of the hand Edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, also known as an infiltration.

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest? Tennis Canoeing Swimming Rowing

Swimming Some exercises, such as swimming and walking, can help clients who have low back pain because they strengthen back muscles.

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 at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Compensate for loss of depth perception. Learn to control impulsive behavior. Improve left-side motor function.

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is caring for a client in the emergency department (ED). Diagnostic Results Day 1 1200: CT scan of lower back, hip, and pelvis region shows hairline fractures to right hip and anterior pelvis. Vital Signs Nurses' Notes Day 1 1200: Temperature 36.4° C (97.5° F) Heart rate 92/min Respiratory rate 22/min Blood pressure 146/85 mm Hg SaO2 95% Day 2 0945: Temperature 37.2° C (98.9° F) Heart rate 108/min Respiratory rate 24/min Blood pressure 154/78 mm Hg SaO2 96% Nurses' Notes Day 1 1100: Client admitted to ED after falling. Client reports pain in right hip and lower back. Alert and oriented to person, place, and time. Bilateral breath sounds are clear. Pedal pulses +2. Skin is pink and warm to touch, movement and sensation intact to extremities. Erythematous and ecchymotic areas noted on the middle to lower back and right hip. Slight edema to sacral and iliac region present. Day 2 0945: Client unable to void and bladder is distended. Indwelling urinary catheter inserted; draining dark, reddish-brown colored urine Edema to sacral and iliac region 2+. Lower extremities cool to touch, pedal pulses 1+ bilaterally, capillary refill time 6 seconds. Select the 4 assessment findings on day 2 that require immediate follow-up. Heart rate Oxygen saturation Edema Temperature Urine color Pedal pulses

Heart rate is correct. The client's heart rate has increased which is a manifestation of unrelieved pain, or an emergent condition, such as a pulmonary embolism. Therefore, this finding requires follow-up by the nurse. Edema is correct. Increased sacral edema can cause impaired circulation and skin breakdown. Therefore, this finding requires follow-up by the nurse. Urine color is correct. Dark, reddish-brown urine is a manifestation of blood in the urine. A pelvic fracture can result in injury to the bladder and ureters. Therefore, this finding requires follow-up by the nurse. Pedal pulses are correct. Decreased pedal pulses are a manifestation of impaired circulation. Therefore, this finding requires follow-up by the nurse.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? Montgomery straps Enzymes Alcohol swabs A transparent dressing

Montgomery straps Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.) Muscle distortion Pain behind the ear Hearing loss Facial twitching Impaired taste

Muscle distortion is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes muscle distortion that gives the affected side a drooping appearance. Pain behind the ear is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes pain behind the ear, in the face, and in the eye on the affected side. Impaired taste is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes impaired taste, as well as difficulties with speech and eating.

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? Pitting edema around the stump dressing Looseness of the stump dressing The dressing forms a cone shape over the stump Figure-eight wrapping around the stump

Pitting edema around the stump dressing If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? Potassium 2.9 mEq/L Phosphorous 4.5 mEq/L Sodium 145 mEq/L Calcium 8.2 mg/dL

Potassium 2.9 mEq/L Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records. Diagnostic Results Medication Administration Record Vital Signs Nurses' Notes Diagnostic Results HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates. UrinalysisResultExpected Reference Range AppearanceClearClear ColorAmberYellow pH5.84.6 to 8.0 Specific gravity1.0121.005 to 1.030 Leucocyte esteraseNegativeNegative NitratesNoneNone CrystalsNoneNone CastsNoneNone Glucose0Negative WBC00 to 4 per low-power field RBC0less than or equal to 2 Medication Administration Record Glargine U 100 25 units subcutaneous at bedtimeFingerstick/random blood glucose before breakfast & bedtime with regular insulin subcutaneous sliding scale coverage: Less than 160 mg/dL: no coverage160 to 220 mg/dL: 2 units221 to 280 mg/dL: 3 units281 to 340 mg/dL: 6 units341to 400 mg/dL: 8 unitGreater than 400: call physician Aldactone 50 mg PO twice dailyDigoxin 0.25 mg PO every morningCarvedilol 25 mg PO twice daily Vital Signs BP 120/72 mm HgTemperature 36.8º C (98.2º F)Pulse rate 88/minRespirations 20/min Nurses' Notes Client received to emergency department from home via private vehicle. Reports fatigue, blurred vision, dizziness, and headache x 2 days. Reports running out of blood glucose strips and Humulin regular insulin due to lack of financial means. States that they are afraid of possible falls from fatigue and dizziness. Lives at home alone. Orders received; will increase glargine from 20 units to 25 units at bedtime. Other meds taken at home remain the same at this time. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Condition Most Likely Experiencing Parameter to Monitor 1 Parameter to Monitor 2

The nurse should teach the client signs of hyperglycemia and assess their feet for sensation because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is indicative of diabetes. The nurse will need to assess for the potential diabetic complication of peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood glucose. This will allow the nurse to determine whether the medication and diet are effective in controlling the client's glucose levels.

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess? The coping ability of the client The client's bowel sounds 24 to 48 The surgical dressing The patency of the NG tube

The surgical dressing When using the airway, breathing, circulation approach to client care, the nurse determines that the assessment priority is monitoring the surgical dressing. Hemorrhage is a major complication postoperatively, so the nurse should assess for early indications of bleeding, such as visible blood stains on the surgical dressing. Covert manifestations of bleeding include rapid, thready pulse, tachycardia, and decreased urine output.

A nurse at an urgent care center is caring for four clients who all have leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain? Dropped a 4.5 kg (10 lb) weight on his lower leg at a health club Has ankle pain after running a 16 km (10 mile) race Twisted his foot while running bases during a baseball game Was hit by another soccer player on the field

Twisted his foot while running bases during a baseball game A sprain is a stretching injury to ligaments around a joint. Wrenching or twisting motions cause this type of injury.

A nurse is teaching a client who has a vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching? Vitamin K reverses warfarin toxicity. Vitamin K promotes fibrinogen formation. Vitamin K is produced in the gastric juices. Vitamin K is produced in the liver.

Vitamin K reverses warfarin toxicity. The nurse should understand vitamin K is an antidote to warfarin toxicity.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? Insert an oral airway. Administer the abdominal thrust maneuver. Turn the client to the side. Perform a blind finger sweep.

Administer the abdominal thrust maneuver. The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.) Affects weight-bearing joints Crepitus can occur in affected joints Affects bilateral, symmetrical joints Causes joint stiffness Causes joint pain

Affects weight-bearing joints is correct. Stress from the use of weight bearing joints can result in joint degeneration and osteoarthritis. Crepitus can occur in affected joints is correct. Clients who have osteoarthritis can develop crepitus, or a grating sound, caused by friction in the joints. Causes joint stiffness is correct. Clients who have osteoarthritis have chronic joint stiffness. Causes joint pain is correct. Clients who have osteoarthritis have chronic joint pain.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Administer epinephrine. Auscultate for wheezing. Monitor for hypotension.

Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? Discard the NPH solution if it appears cloudy. Shake the insulin vigorously before loading the syringe. Expect the NPH insulin to peak in 6 to 14 hr. Freeze unopened insulin vials.

Expect the NPH insulin to peak in 6 to 14 hr. NPH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14 hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak time.

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? All visitors from entering the client's room Fresh flowers and potted plants in the room Oral fluid intake to between meals only Activities that could result in bleeding

Fresh flowers and potted plants in the room Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed fruits and vegetables. Immunocompromised clients are more susceptible to infection and illness from food-borne bacteria than other clients.

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect? Hyperpigmentation Intention tremors Hirsutism Purple striations

Hyperpigmentation Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? Numbness of toes on the affected foot Hypothermia Localized erythema Bradycardia

Localized erythema Swelling and localized erythema are manifestations of acute osteomyelitis.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A family history increases your risk for acquiring hepatitis A. Hepatitis A infects the kidneys. Manifestations of the virus are similar to flu-like symptoms. The incubation of the virus is 5 days.

Manifestations of the virus are similar to flu-like symptoms. The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

A nurse is caring for a client. Nurses Notes 1410: The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Bowel sounds positive x 4 quadrants. The client's tympanic temperature is 37.2 ° C (99.0° F). Respiratory rate 22/min Lung sounds clear bilaterally. (Oxygen saturation is 96 % on room air. Heart rate 110/min Blood pressure 88/58 mm Hg while lying down. Casual capillary blood glucose is 145 mg/dL. A nurse is caring for a 26-year-old client who has abdominal pain. Click to highlight the findings below that the nurses should report to the provider. To deselect a finding, click on the finding again. Nurses' Notes The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Bowel sounds positive x 4 quadrants. The client's tympanic temperature is 37.2 ° C (99.0° F). Respiratory rate 22/min Lung sounds clear bilaterally. Oxygen saturation is 96 % on room air. Heart rate 110/min Blood pressure 88/58 mm Hg while lying down. Casual capillary blood glucose is 145 mg/dL.

Nurses' Notes The client reports abdominal pain for the last two days that is now moving to the right lower quadrant. The pain has started to increase over the last hour and is a 9 on a 0 to 10 scale. Bowel sounds positive x 4 quadrants. The client's tympanic temperature is 37.2 ° C (99.0° F). Respiratory rate 22/min Lung sounds clear bilaterally. Oxygen saturation is 96 % on room air. Heart rate 110/min Blood pressure 88/58 mm Hg while lying down. Casual capillary blood glucose is 145 mg/dL.

A nurse is caring for an older adult client who has had a total hip arthroplasty. Medical History Osteoporosis Nurses' Notes Day 1 1750, post-operative note: Vital signs stable; staples to right THA incision covered with gauze, secured with tape. Bilateral pedal pulses +2, lower extremities warm. Client lethargic, no nausea/vomiting. Bowel sounds x 4 hypoactive, transfer report called to orthopedic unit. 2300: Client alert and oriented to person and place with episodes of confusion. Rates pain as 6 on 0 to 10 scale. Incision site has small amount of serous drainage on dressing. Bilateral pedal pulses +2, lower extremities warm; no nausea/vomiting; bowel sounds x 4 active 0.45% sodium chloride 1000 mL infusing at 75 mL via continuous to left forearm peripheral IV site. Lung sounds diminished bilateral bases. Day 2 0600: Client is alert and oriented to person and place, but becoming more confused. Rates pain of right hip as 7 on 0 to 10 scale. Client moving operative leg in bed and trying to get up without assistance. Reminded to keep leg straight and ask for help to get out of bed. Redness around incision dressing with large amount of serous sanguineous drainage on dressing with foul odor. +2 bilateral pedal pulses. Affected extremity warm to touch. Bowel sounds normoactive in all 4 quadrants. Lung sounds diminished in bilateral bases. Client requests something to eat and drink; also requests pain medication for pain level of "3 to 6 maybe" on 0 to 10 scale 0615: Oxycodone 10 mg PO administered for pain; call bell within reach, side rails X 2 up. For each potential precaution, click to specify if the precaution is indicated or contraindicated for a client who has had a total hip arthroplasty. Assessment Findings Indicated Contraindicated Encourage the client to cough and deep breathe every 2 hr. Anticipate the administration of antibiotics. Obtain a culture of the drainage from the surgical site. Request an antiemetic medication. Ensure an abductor pillow is in place while the client is in bed.

Obtain a culture of the drainage from the surgical site is indicated. The client has redness around the dressing site with large amount of serous sanguineous drainage on dressing with foul odor which can indicate and infection. Encourage client to cough and deep breathe every 2 hr is indicated. Following surgery, the nurse should instruct the client to cough and deep breathe every 2 hr to promote lung expansion and prevent atelectasis. Ensure an abductor pillow is in place while the client is in bed is indicated. The nurse should reinforce to the client to keep the operative leg straight. The use of an abductor pillow should be placed between the client's legs while in bed to prevent dislocation of the hip. Request an antiemetic medication is contraindicated. The client reports no nausea or vomiting at this time. Anticipate the administration of antibiotics is anticipated. The client is becoming more and more confused and has a fever. There is also redness around the dressing site with a large amount of serous sanguineous drainage with a foul odor which can indicate and infection.

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine? Pale pink Bright yellow Bright red Dark amber

Pale pink The client should expect to pass some small clots and tissue in his urine for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery, around the time of discharge, his urine should be clear yellow.

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? Avoid eating at fast food restaurants. Avoid serving raw foods. Practice effective hand hygiene. Wear barrier protection during vaginal intercourse.

Practice effective hand hygiene. Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A.

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? Ambulate the client four times per day. Encourage the client to consume clear liquids. Provide frequent oral and nares care. Keep the client in a supine position.

Provide frequent oral and nares care. A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions.

A nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax. Which of the following is appropriate to include in the plan of care? Provide respiratory support. Place the client in droplet isolation. Administer antihypertensive medications. Monitor ascites.

Provide respiratory support. As the infection from an inhaled form of anthrax progresses, the client develops increasingly serious respiratory symptoms including severe respiratory distress, stridor, cyanosis, hypotension, and shock. The nurse should plan to provide respiratory support in the form of mechanical ventilation.

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? Reduces inflammation Suppresses the urge to cough Dries mucous membranes Stimulates secretions

Stimulates secretions Expectorants act by increasing secretions to improve a cough's productivity.

A nurse in the emergency department is caring for a female client. Nurses' Notes Client appears lethargic and reports fatigue, a decrease in appetite, and a 20 lb weight gain over a 6-month period. Client reports hair loss and numbness and tingling in fingers. Neck midline with a 1+ goiter. Skin is pale, cool, and dry. Client reports constipation. Abdomen is distended. Bowel sounds are hypoactive. Vital Signs Temperature 35.9º C (96.6º F)Blood pressure 88/60 mm HgHeart rate 58/minRespiratory rate 14/minOxygen saturation 93% on room air Diagnostic Results 0800:Cortisol (serum) 16 mcg/dL (5 to 23 mcg/dL) Serum T3 60 ng/dL (70 ng/dL to 205 ng/dL) Serum T4 (total) 3 mcg/dL (5 mcg/dL to 12 mcg/dL) FLAG A nurse in the emergency department is caring for a female client. Nurses' Notes Vital Signs Diagnostic Results Diagnostic Results 0800:Cortisol (serum) 16 mcg/dL (5 to 23 mcg/dL) Serum T3 60 ng/dL (70 ng/dL to 205 ng/dL) Serum T4 (total) 3 mcg/dL (5 mcg/dL to 12 mcg/dL) Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Condition Most Likely Experiencing Parameter to Monitor 1 Parameter to Monitor 2 Actions to Take Potential Condition Parameters to Monitor

The nurse should request a prescription for thyroid hormone replacement and provide the client with supplemental oxygen because the client is most likely experiencing hypothyroidism. The client has a decreased oxygen saturation and thyroid function. The nurse should monitor the client's oxygen saturation because the client is at risk for myxedema coma and respiratory failure. The nurse should monitor the client's bowel function to assess the client's progress.

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.) The student should use his quick-relief inhaler. The student's asthma is not well controlled. The student's peak flow is 50% to 80% of his best peak flow. The student needs to go to the hospital. The nurse should obtain a second expiratory flow rate.

The student should use his quick-relief inhaler is correct. The student should use his quick-relief inhaler is correct. A student in the yellow zone should use a quick-relief inhaler such as albuterol to reverse airway obstruction. The student's asthma is not well controlled is correct. The student's asthma is not well controlled is correct. The yellow zone indicates that the student's asthma is not well controlled. The desired range is the green zone which is represents 80 % of the client's personal best. The student's peak flow is 50% to 80% of his best peak flow is correct. The student's peak flow is 50% to 80 % of his best peak flow is correct. This is the range for a client who is in the yellow zone. The nurse should obtain a second expiratory flow rate is correct. The nurse should obtain a second expiratory flow rate is correct. The second peak flow rate should be obtained after the student uses his quick-relief inhaler.