Care Management Final

4. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

"Antihistamines do not help poison ivy."

A client has been newly diagnosed with systemic lupus erythematous and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material?

"Baby powder is good for the constant sweating."

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in the client's teaching?

"Call your primary health care provider for diarrhea."

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.)

"Chemo" gloves Face mask Impervious gown Eye protection

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatment for cancer. What response by the nurse is most appropriate?

"Do not expose the radiation area to direct sunlight'"

A nurse has educated a client on an epinephrine auto injector. What statement by the client indicates additional instructions is needed?

"I don't need to go to the hospital after using it."

3. After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching?

"I will weigh myself each morning before I eat or drink."

4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is the most appropriate?

"It is normal to be fatigued even for months afterward."

A client is receiving rituximab and asks how it works. What response by the nurse is best?

"It prevents the start of cell division in the cancer cells."

18. The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?

"It's alright for me to keep my pets and change the litter box."

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in the patient s teaching?

"Make sure you clean the humidifier to precent infections."

A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate the client correctly understood the teaching? (Select all that apply.)

"Nasal saline sprays will help to prevent rebreeding." "I will wait at least 1 month to resume weightlifting." "I will apply small amount of petroleum jelly to my nares."

An assistive personeel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?

Assess the client's lung sounds

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

Assess the client's lung sounds every 2 hours.

12. A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the client's respiratory rate, rhythm, and depth.

A nurse cares for a client who has packing inserted to posterior nasal bleeding. What action would the nurse take forest?

Assess the clients airway

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the clients face is puffy and the eyelids are swollen. What action by the nurse is best?

Assess the clients oxygen saturation

6. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

Assessing the IV site and blood return every hour

A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery?

Assist the client to choose a communication method

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem?

Assisting the client to a pre-plan for this event

A client has mucositis. What action by the nurse will improve the clients nutrition? (Select all that apply.)

Assisting with rinsing the mouth with saline frequently Encourage the client too eat room-temperature foods Provide local anesthetic medications to swish and spit Offer the client fluids to drink each hour

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

Auscultate lung sounds.

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction?

Bends both knees, pushes against the bed until calf and thigh muscles contract.

13. A client is receiving rituximab. What assessment by the nurse takes priority?

Blood pressure

5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic changes when standing.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision.

9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?

Depth of respirations

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?

Determine if the client can switch to a nasal cannula during the meal

The nurse is assessing a client for signs and symptoms of systemic lupus erythematous (SLE). Which of the following would be consistent with this disorder? (Select all that apply.)

Discoid rash on skin exposed to sunlight Urinalysis positive for casts and protein Pain on inspiration Serum positive for antinuclear antibodies (ANA)

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

Disposing of dressings properly Performing proper hand hygiene Removing and replacing wet dressings

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the primary health care provider.

7. A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: (picture Swollen face/Angioedema). What action by the nurse is most appropriate?

Ensure a patent airway while calling the Rapid Response Team

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

Ensure that informed consent is on the chart

A client is being administered the first dose of belimumab for a systemic lupus erythematosus flare. What actions by the nurse are most appropriate? ( Select all that apply.)

Observe the client for at least 2 hours afterward Ensure emergency equipment is working and nearby

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care?

Older adult who lives alone at home despite some memory loss.

2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

Assess client further for fall risk.

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Apply the clients shoes before getting the client out of bed Assist the client with ambulation Use a lift sheet to move the client up in bed

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)?

Apply water-soluble ointment to nares and lips

A nurse cares for a client who has a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?

"This is normal after surgery. What types of food do you like to eat?"

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate?

"Use the prescribed solution and wash the area where you will have surgery very thoroughly."

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patients teaching? (Select all that apply.)

"You will need to cut the wires if you start vomiting." "Eat six soft or liquid meals each day while recovering." "Use a water pick for dental hygiene until you can brush again." "Sleep in a semi-Fowler position after the surgery."

A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material?

"if Lyme diseases not treated successfully, it is usually fatal."

7. A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed?

Applying suction while inserting the catheter

2. A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation

ANS: A Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. The nurse responds by performing a thorough cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal system, and neurologic system, but assessing for the cardiovascular complications comes first.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.)

A 24 year old with a traumatic brain injury A 58 year old getting radiation therapy A 66 year old who is a quadriplegic An 80-year-old who is aphasic

7. A nurse is assessing clients for fluid and electrolyte imbalance;ances. Which client will the nurse assess first for potential hyponatremia?

A 34 year old who is NPO and receiving rapid intravenous D5W infusions.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year old woman who is 50 lbs (23kg) overweight

1. A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?

A 76 year old who is cognitively impaired.

13. A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

ANS: A All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Applying water soluble lip balm to the clients lips Reminding the client to cough and deep breath often

6. A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the primary health care provider.

ANS: A Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings would be documented, but simply continuing to monitor is not sufficient. Before notifying the primary care provider, the nurse must have more data to report.

1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

ANS: A This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are signs and symptoms of hyperglycemia but are not compensatory mechanisms foracid-base imbalances. The kidneys do not release acids.

8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client can breathe again normally, so oxygen administration will rapidly increase the PaO2. Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are administered to decrease the high potassium levels associated with acidosis, but this situation should reverse itself with oxygen and breathing.

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough.

ANS: A A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client's airway is not at risk with this skin disorder. Applying gloves will help prevent transmission.

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin. c. Brush any visible dust off the skin. d. Call poison control for guidance

ANS: A With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

3. A clinic nurse is working with an older client. What action is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

17. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug? a. Does not reduce the need for safe sex practices. b. Has been taken off the market due to increases in cancer. c. Reduces the number of HIV tests you will need. d. Is only used for postexposure prophylaxis.

ANS: A Tenofovir/emtricitabine is a newer drug used for preexposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis

8. A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate? a. Administer antibiotics. b. Place the client in isolation. c. Administer IV leukocytes. d. Obtain an immunization history.

ANS: A A bandemia, or shift to the left, in the white count differential means that an acute, continuing infection has placed so much stress on the immune system that the most numerous type of neutrophil in circulation are immature, or band cells. The nurse would anticipate administering antibiotics. The client may or may not need isolation. Leukocyte infusion and immunization history are not relevant.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the client for anxiety.

3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet (1 m) of the client

ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Standard Precautions are required by the CDC. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet (1 m) of the client is not necessary with every client contact.

7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

9. A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

ANS: A All of the actions are important, but due to the infectious nature of this illness, the nurse would ensure he or she is following Standard Precautions (and Transmission-Based Precautions when necessary) to avoid a potential exposure.

19. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

ANS: A Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

2. The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus in addition to providing mucus membrane contact with the virus.

2. A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request the primary health care provider order blood cultures

ANS: A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse would assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment

5. An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

ANS: A Clients who survive a lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse would prioritize the ECG over the other assessments which would be completed later.

9. What does the nurse learn about the function of colony-stimulating factor? a. Triggers the bone marrow to shorten the time needed to produce mature WBCs. b. Causes capillary leak in acute inflammation. c. Responsible for creating exudate (pus) at infectious sites. d. Dilates blood vessels at the site of inflammation leading to hyperemia.

ANS: A Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce mature WBCs from about 14 days to hours. Increased blood flow to the local area of inflammation produces hyperemia, or redness. Exudate is formed by neutrophils and consists of dead WBCs, necrotic tissue, and fluids that escape from damaged cells. Histamine, serotonin, and kinins dilate arterioles leading to redness and warmth.

13. A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan? a. Store basic supplies to last for at least 3 days. b. Have short-term arrangements for child care. c. Store enough frozen foods in freezer for 5 days. d. Keep cooking utensils needed in a separate bag.

ANS: A Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan with enough supplies for 3 days. Any food needs to be nonperishable with no cooking required. Arrangements for children, pets, or older adults would be made for extended period of time

14. What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

ANS: A ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next?

Assess the client for obstructive sleep apnea

10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse

ANS: A In this emergency situation, the nurse immediately initiates airway clearance and ventilator support measures, including delivering rescue breaths.

14. A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on? a. Cardiopulmonary b. Integumentary c. Peripheral vascular d. Renal

ANS: A Lightning strikes can profoundly affect the cardiopulmonary and the central nervous system as a serious cardiac and/or respiratory arrest. The nurse would be alert for reports of chest pain and would watch for dysrhythmias on the cardiac monitor. As impairment of the respiratory center can also be affected, the nurse would assess the respiratory system second.

6. A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency.

ANS: A People would never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client

7. A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Patients experience severe pain during the rewarming process and nurses would administer intravenous analgesics.

5. A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

ANS: A The B-cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B-cells.

5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 21 days. The confirmatory Western Blot test takes an additional 7 days, so using that testing algorithm, the client's status may not truly be known for up to 28 days. The client may have had exposure that has not yet been confirmed. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. Testing would be recommended every 3 months for someone engaging in high risk behaviors.

8. A nurse wants to become involved in community disaster preparedness and is interested in helping setup and staff first-aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first-aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search-and-rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

4. An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? a. Administer dexamethasone. b. Complete a mini mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not specifically treat HACE, although a thorough mental status exam would be performed

13. A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse would help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state, but the nurse would be the client's advocate and help ensure his or her wishes are met.

14. A client with HIV-II is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times

ANS: A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs and food. The nurse would consult with a pharmacist about possible interactions. Client teaching is important but does not take precedence over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.

12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.

1. The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 109 /L). What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A This client is in the Centers for Disease Control and Prevention HIV-II case definition group. He or she remains highly infectious and would be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required, although some medications may need to be taken while abstaining. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take precedence over stopping the spread of the disease.

11. A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A This client needs the assistance of support systems. The nurse would help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Positive HIV test results are reportable in all 50 states, Washington, D.C., and Canada but the nurse works with the client to support his or her choices in disclosure. The nurse would not tell the family for the client

1. A hospital responds to a local mass casualty event. What action would the nurse supervisor take to prevent staff posttraumatic stress disorder during and after the event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

ANS: A To prevent staff posttraumatic stress disorder during a mass casualty event, the nurses would use available counseling, encourage and support co-workers, monitor each other's stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses would also keep in touch with family, friends, and significant others, and not work for more than 12 hours/day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent posttraumatic stress disorder. These actions also help mitigate PTSD after the event

18. A client in the emergency department has several broken ribs and reports severe pain. What care measure will best promote comfort? a. Prepare to assist with intercostal nerve block. b. Humidify the supplemental oxygen. c. Splint the chest with a large ACE wrap. d. Provide warmed blankets and warmed IV fluids

ANS: A Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.

9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

ANS: A When deployed, DMAT health care providers act as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

2. A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18 mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau sign f. Flaccid paralysis

ANS: A, B, C Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. Flaccid paralysis can occur. A positive Trousseau sign is associated with alkalosis. Decreased urine output is not a sign of metabolic acidosis.

11. For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

9. A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) a. Bilateral crackles b. Bradycardia c. Cyanosis of the lips d. Hypotension e. Flushed, diaphoretic skin

ANS: A, B, C, D Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as a response to asphyxia produces bradycardia, signs of decreased cardiac output with hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.

18. A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with HIV-I disease are not infectious to others. f. The CD4+ T-cell is only affected when the disease has progressed to HIV-III

ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produce are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in client's with HIV infection. People infected with HIV are infectious in all stages of the disease. The CD4+ T-cell is the immune system cell most affected by infection with the HIV virus.

9. A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.) a. Veterans have a high prevalence of substance abuse. b. Many veterans may engage in high risk behaviors. c. Many older veterans may not know their risks. d. Everyone should know their HIV status. e. Belief that the VA has tested them and would notify them if positive

ANS: A, B, C, D, E All options are correct for the veteran population. The nurse interacting with veteran would ensure they know about the HIV testing offered by the VA.

18. A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (Select all that apply.) a. Know the institution's Emergency Response Plan. b. Participate in the institution's disaster drill. c. Develop a personal preparedness plan. d. Understand that nurses play a role in every phase of a disaster. e. Be prepared to report immediately to the emergency department. f. Be willing to be flexible working during a crisis situation

ANS: A, B, C, D, F Nurses play a major role in disaster and need to be prepared for any type of disaster. Knowing the institution's emergency management plan and participating in disaster drills will help the nurse be prepared for a disaster. Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan. Nurses play key roles before, during, and after a disaster in the development of emergency management plan in defining specific nursing roles. During a crisis, nurses may be assigned to different areas of the facility or to different job functions and must remain flexible while working to their best ability

4. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

ANS: A, B, C, D, F The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.

3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions

ANS: A, B, C, E, F Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.

6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.

17. The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection. c. Show expected changes in white blood cell counts. d. Should receive influenza, pneumococcal, and shingles vaccinations. e. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages.

ANS: A, B, D, E Immunity changes during an adult's life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased risk for bacterial and fungal infections due to the decreased number of circulating T-lymphocytes.

16. The nurse learns that which risk factors can affect immunity? (Select all that apply.) a. Age b. Environmental factors c. Ethnicity d. Drugs e. Nutritional status

ANS: A, B, D, E Immunity changes during an adult's life as a result of nutritional status, environmental conditions, drugs, disease, and age. Immunity is most efficient in young adults and older adults have decreased immune function. Ethnicity does not affect immunity.

5. A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that apply.) a. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. c. Soak eschar daily until it softens and can be removed. d. Consult with a registered dietitian nutritionist. e. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adjuvant therapies for nonhealing wounds.

ANS: A, B, D, E, F Best practice for pressure injury wound management includes ongoing assessments that include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar.

The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum

ANS: A, B, D, E, F Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center.

14. Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization f. Production

ANS: A, B, D, E, F The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

24. The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.) a. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. c. Clean your toothbrush in the dishwasher daily. d. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds. f. Make sure meat, fish, and eggs are cooked well.

ANS: A, B, D, E, F Ways to avoid infection when immunocompromised include not working in the garden or with houseplants; not emptying litter boxes; running the toothbrush through the dishwasher at least weekly; bathing daily using antimicrobial soap; avoiding sick people and large crowds; and making sure meat, fish, and eggs are cooked well prior to eating them.

1. A nurse is planning interventions that regulate acid-base balance to ensure that the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs f. Changes in GI tract excitability

ANS: A, B, D, F Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs.

19. Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 (0.2 109 /L) or less than 14% b. Infection with P. jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications f. Confusion, dementia, or memory loss

ANS: A, B, D, F A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 (0.2 109 /L) or less than 14% (even if the total CD4+ count is above 200 cells/mm3 ) or an opportunistic infection such as P. jiroveci and HIV wasting syndrome. Confusion, dementia, and memory loss are central nervous system indications. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

21. What statements about the complement system are correct? (Select all that apply.) a. Comprised of 20 types of inactive plasma proteins. b. Act as enzymes when activated to enhance innate immunity. c. Phagocytize foreign invaders quickly by destroying their membranes. d. Sticks to the antigen and forms a membrane attack complex. e. Maintain and prolong inflammation from non-self cells. f. Is part of the innate immune system.

ANS: A, B, D, F The complement system is made up of 20 different types of inactive plasma proteins that, when activated, act as enzymes to enhance (or complement) cell actions in innate immunity. They join other proteins to surround antigens and "fix" or stick to the antigen quickly forming a membrane attack complex on the antigen surface. This action makes immune cell attachment to antigens and phagocytosis more efficient. They are part of innate immunity. They do not phagocytize invaders themselves nor do they maintain and prolong inflammation from allergens.

17. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation Precautions f. Safety concerns

ANS: A, B, E, F Hand-off communication would be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication would be concise and would include only the most essential information for a safe transition in care. Hand-off communication would include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, safety concerns interventions provided, and response to those interventions. Immunization history is not usually considered critical unless it relates to the reason for admission. Medication reconciliation will occur when the client reaches the inpatient unit.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. People with substance abuse disorders c. Caucasians d. Hockey players e. Older adults f. Obese individuals

ANS: A, B, E, F Some of the most vulnerable, at-risk populations for heat-related illness include older adults; people who work outside, such as construction and agricultural workers; homeless people; people who abuse substances; outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan). Hockey is generally a cold-air game whether played indoors or outdoors and wouldn't have as much risk for heat-related illness as other sports.

17. A nurse teaches a client who has severe allergies ways to prevent insect bites. Which statements does the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine autoinjector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering." f. "Identify and remove potential nesting sites in your yard."

ANS: A, B, E, F To prevent arthropod bites and stings, patients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine autoinjector at all times if they are known to be allergic to bee or wasp stings. Shoes are needed when working in areas known or suspected to harbor arthropods, but sandals will not protect the feet. Removing nesting sites may help eliminate the population.

20. The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired with the correct information? (Select all that apply.) a. Abacavir: avoid fatty and fried foods. b. Efavirenz: take 1 hour before or 2 hours after antacids. c. Atazanavir: check pulse daily and report pulse greater than 100 beats/min. d. Dolutegravir: do not take this medication if you become pregnant. e. Enfuvirtide: teach client how to operate syringe infusion pump for administration. f. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

ANS: A, B, F Abacavir is a nucleoside reverse transcriptase inhibitor and clients are taught to avoid fried and fatty foods because they can lead to digestive upsets and even pancreatitis. Efavirenz is a nonnucleoside reverse transcriptase inhibitor and clients are taught to take them (doraverene) all except spaced 1 hour before or 2 hours after antacids to avoid inhibiting drug absorption. Atazanavir is a protease inhibitor and can cause bradycardia which should be reported. Dolutegravir is an integrase inhibitor and can cause birth defects. Enfuvirtide is a fusion inhibitor and is given subcutaneously. All drugs must be taken as scheduled 90% of the time in order to remain effective.

A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client to report lesions near the eyes. b. Have the client take long, hot baths to soak the lesions. c. Show the client how to make a baking soda compress. d. Advise the client to avoid exposure to UV light rays. e. Demonstrate proper use of antifungal medications. f. Review appropriate hygiene measures.

ANS: A, C This client has herpes zoster (shingles). Eye infection is possible, so the client should be taught to report any lesions erupting near the eyes. Comfort measures can include compresses, calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal medications are not used. Hygiene is not an issue causing an outbreak.

9. A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly matched to their function? (Select all that apply.) a. IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. b. IgD: provides protection against parasite infestations, especially helminths. c. IgE: associated with antibody-mediated immediate hypersensitivity reactions. d. IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.

ANS: A, C, D, E All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection against parasite infestations, especially helminths.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?

Assess the client's gait and balance

15. The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B-cell.

ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

14. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries would be treated within 30 minutes to 2 hours, and therefore would be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags

18. A nurse is providing health education at a community center. Which instructions does the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools

ANS: A, C, D, F When thunder is heard, individuals should seek shelter in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects such as golf clubs or gardening tools. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning.

8. A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? (Select all that apply.) a. Monocyte: matures into a macrophage. b. Basophil: releases vasoactive amines during an allergic reaction. c. Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins. e. Natural killer cell: nonselectively attacks non-self cells. f. Regulator T-cells: become sensitized for self-recognition in the bone marrow.

ANS: A, C, E Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack and destroy non-self cells, including virally infected cells, grafts, and transplanted organs. Regulator T-cells become sensitized for self-recognition in the thymus.

7. A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the following are potentially correct ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures

ANS: A, C, E The client with ARDS who needs mechanical ventilation benefits from "open lung" and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight). Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client.

7. Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Headache and fatigue c. Hypotension d. Presence of perspiration e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C)

ANS: A, C, E, F Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with colloidal oatmeal e. Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

15. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag f. A 33-year-old male unconscious with bilateral leg amputations: yellow tag

ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that need to be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag. The client with the amputated legs will probably be black tagged if the unconsciousness is from massive blood loss.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Client with a respiratory rate of 6 breaths/min

21. A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) a. Have the client lie down in a cool place. b. Force fluids with large quantities of plain water. c. Administer acetaminophen and send home. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink. f. Remove all clothing and cover with a towel.

ANS: A, D, E Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin. Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

20. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. f. Insert an indwelling urinary catheter for urine output measurements.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

21. A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL (88 mcmol/L) d. Platelet count: 80,000/mm3 (80 109 /L) e. Serum sodium: 120 mEq/L (120 mmol/L) f. Serum potassium: 3.4 mEq/L (3.4 mmol/L)

ANS: A, D, E The drug of choice to treat P. jiroveci pneumonia is trimethoprim with sulfamethoxazole. Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium would all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal and the potassium is just below normal.

10. The nurse caring for clients assesses their daily laboratory profiles. Which lab results are considered to be in the normal range? (Select all that apply.) a. Segmented neutrophils: 68% b. Bands: 19% c. Monocytes: 12% d. Lymphocytes: 38% e. Eosinophils: 2% f. Basophils: 1%

ANS: A, D, E, F The normal range for segmented neutrophils is 55% to 70%. The normal range for bands is 5%. The normal range for monocytes is 2% to 8%. The normal range for lymphocytes is 20% to 40%. The normal range for eosinophils is 1% to 4%. The normal range for basophils is 0.5% to 1%.

13. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. Decreased function

ANS: A, D, E, F The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

16. A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent overheating." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached." f. "Change your gloves and socks if they become wet."

ANS: A, D, E, F To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and a hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients need to know their physical limits and come in out of the cold when these limits have been reached. Wet clothing contributes to heat loss so clients would be taught to change any clothing that becomes wet.

A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance would the nurse assess? (Select all that apply.) a. Positive Chvostek sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability f. Tetany

ANS: A, E A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and anxiety and irritability.

12. An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the patient. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.

ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency department nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or stereotypical remarks, shows genuine care and concern by listening, and follows through on promises. The nurse would also respect the client's belongings and personal space.

19. The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

ANS: B Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred. The client who would have these ABG values is the one with the new onset of airway obstruction.

9. After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."

ANS: B Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking pain medications with antihistamines, and salting food are not related.

15. A diabetic client becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50, PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance? a. Atelectasis due to respiratory muscle fatigue b. Hyperventilation due to poor oxygenation c. Hypoventilation due to morphine PCA d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L)

ANS: B The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by low partial pressure of arterial oxygen causing a compensatory mechanism of increased respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would cause respiratory acidosis with a low pH and high PaCO2. Kussmaul respirations are characterized by deep labored breathing and are a compensatory mechanism to metabolic acidosis, not hypoxemia or alkalosis.

10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

ANS: B The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis and COPD would lead to respiratory acidosis. The client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

14. A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L). Which question would the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?

ANS: B The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance. The other three questions are also yes/no and close-ended.

5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek sign

ANS: B The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign are signs and symptoms of the electrolyte imbalances that accompany alkalosis.

12. A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? a. Furosemide 40 mg b. Sodium bicarbonate c. Mechanical ventilation d. Indwelling urinary catheter

ANS: B This client's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client's acid-base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client's pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for that client.

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily.

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions.

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.

ANS: B As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

A nurse assesses a client who has psoriasis. Which action would the nurse take first? a. Don gloves and an isolation gown. b. Shake the client's hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy would be completed after establishing a report with the client.

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dermabrasion or chemical peels can be done in the office." b. "I may need lymph node resection during Mohs surgery." c. "This needs only a small excision with local anesthetic." d. "After surgery I will need 8 weeks of radiation therapy."

ANS: B Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells. Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma.

After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Green salad, a banana, whole wheat dinner roll, coffee b. Chicken breast, broccoli, baked potato, ice water c. Vegetable lasagna and green salad, iced tea d. Hamburger, fruit cup, cookie, diet pop

ANS: B Successful healing of pressure injuries depends on adequate intake of calories, protein, vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The other dinners while having some healthy items each, are not as nutritious.

A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information? a. "At the next family reunion, I'm going to ask my relatives if they have anything similar." b. "I have to make sure I keep my lesions covered, so I do not spread this to others." c. "I must avoid large crowds and sick people while I am taking adalimumab." d. "I will buy a good quality emollient to put on my skin each day."

ANS: B This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects. Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands. b. Irregular mole with multiple colors on the leg. c. Large cluster of pustules in the right axilla. d. Thick, reddened papules covered by white scales.

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Freckles are a benign condition. Pustules could mean an infection, but it is more important to assess the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L3 (9.2 109) b. Boggy feel to granulation tissue c. Increased size after debridement d. Requesting pain medication

ANS: B Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual.

5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C)

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy?

Decreased immune function

6. A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time to be effective. Since this client's viral load has increased dramatically, the nurse would first assess this factor. After this, the other assessments may or may not be needed.

10. The older client's adult child questions the nurse as to why the client is at higher risk for infection when the client's white cell count is within the normal range. What response by the nurse is best? a. "The white cell count does not tell us everything about immunity." b. "White blood cells are less active in older people so they are not as efficient." c. "Older people typically have poor nutrition which makes them prone to infection." d. "As one ages, immunoglobulins cease to be produced in response to illness."

ANS: B An age-related change in immunity is that neutrophils in the older adult are less active and therefore less effective in immunity. The white blood cell count is not the only thing that can inform about immunity, but this response is too vague to be useful. Many older adults do have poor nutrition that does affect immunity, but this is not true for everyone and the stem does not contain information stating that is problematic for this older adult. Immunoglobulins do not cease to be produced with age.

10. After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question would the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

ANS: B Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can "stand down."

12. A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."

ANS: B Black widow spider venom can produce muscle rigidity and spasms, which are treated with the muscle relaxant, diazepam. It does not prevent respiratory difficulty or failure nor is it antivenom.

15. A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

ANS: B Cryptosporidiosis can cause diarrhea and wasting with extreme loss of fluids and electrolytes. The nurse would assess signs of hydration/dehydration as the priority, including checking the client's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.

4. A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process

4. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse would contact the regional poison control center immediately for specific advice on antivenom administration and client management.

12. A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or symptom would be most important for the nurse to report to the primary health care provider? a. Nausea b. Change in pupil size c. Weeping open lesions d. Cough

ANS: B HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement. The nurse would report any sign of increasing intracranial pressure immediately, including change in pupil size, level of consciousness, vital signs, or limb strength. The other signs and symptoms are not life threatening and would be documented and reported appropriately

13. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival

1. A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority?

Never stop prednisone abruptly.

2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he or she wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the patient. d. Refer the client's spouse to the hospital's crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I—located within remote areas and provides advanced life support within resource capabilities b. Level II—located within community hospitals and provides care to most injured clients c. Level III—located in rural communities and provides only basic care to clients d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients

ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made

3. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client's trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first

5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient's temperature or improve the patient's symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

15. A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.

ANS: B The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS.

6. A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.)

Ask the family to describe their concerns more fully. Consult with a social worker, chaplain, or ethics committee. Explain the client's right to know and ask for their assistance.

20. A nurse evaluates the following data in a client's chart: Admission Note Laboratory Results Wound Care Note A 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 (8 109/L) Prealbumin: 15.2 mg/dL (152 mg/L) Albumin: 4.2 mg/dL (42 mg/L) Lymphocyte count: 2000/mm3 (2 109/L) Sacral ulcer: 4 2 1.5 cm Based on this information, which action would the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the client's vital signs.

ANS: B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse would request a dietary consult. The other interventions do not address the information provided.

1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

22. A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Reports feeling frightened "Can't catch my breath" pH: 7.32 PaCO2: 28 mm Hg PaO2: 78 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

ANS: B This client has signs and symptoms of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse would facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

21. A nurse evaluates the following data in a client's chart: Admission Note Prescriptions Wound Care A 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Negative-pressure wound therapy (NPWT) to leg wound Based on this information, which action would the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the primary health care provider to discuss the treatment c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

ANS: B A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding complications. The health care primary health care provider needs this information quickly to plan other therapy for the client's wound. The nurse would contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are appropriate for a client who has a history of atrial fibrillation and would be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring

6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 109 /L) c. Red blood cell count: 4.8/mm3 (4.8 1012/L) d. White blood cell count: 8700/mm3 (8.7 109 /L)

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

5. A nurse is planning care for a client who is lethargic and confused. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been participating in strenuous activity?" e. "Are you experiencing any shortness of breath?"

ANS: B, C, D This client's symptoms of lethargy and confusion are related to a state of metabolic acidosis. The nurse would ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis. Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other options are not causes of metabolic acidosis.

10. The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Use sunscreen with an SPF of at least 15 when outdoors. b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day. e. Wear light-colored, snugly-fitting clothing to wick sweat away.

ANS: B, C, D To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

9. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure that all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.

12. A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses

6. A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

ANS: B, C, D, E The AP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

25. A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.) a. Anyone who received a blood product in 1989 b. Couples planning on getting married c. Those who are sexually active with multiple partners d. Injection drugs users e. Sex workers and their customers f. Adults over the age of 65 yea

ANS: B, C, D, E The CDC recommends that HIV testing would be performed on those who received a transfusion between 1978 and 1985 only. People planning on getting married should be tested and all sexually active people should know their HIV status. Those engaged in sex work and their customers should also be tested, as well as injection drug users. Those over the age of 65 years need a one-time screen.

16. A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Use facility policy identification procedures for "Jane/John Doe" clients. f. Check clients for a medical alert bracelets or necklaces. g. Avoid using Security personnel to prevent escalation of client behaviors.

ANS: B, C, D, E, F Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up, using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.

3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis—older adult who is following a carbohydrate-free diet c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis—postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux disease

ANS: B, C, E Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, but also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

3. An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

5. A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush. f. Offer the client soft foods like gelatin or pudding.

ANS: B, C, E, F The AP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Soft foods and liquids are tolerated better than harder foods. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and would not be used.

10. A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic—decides the number, acuity, and resource needs of clients b. Hospital incident commander—assumes overall leadership for implementing the emergency plan c. Public information officer—provides advanced life support during transportation to the hospital d. Triage officer—rapidly evaluates each client to determine priorities for treatment e. Medical command physician—serves as a liaison between the health care facility and the media

ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE

16. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients would the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care f. Client with symptoms of influenza after traveling abroad

ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care could be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit would be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis. The client who has recently traveled abroad may have either seasonal influenza or may have a novel or potential pandemic respiratory virus and should not be transferred to avoid spreading the illness.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

ANS: B, E, F Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

11. After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

ANS: C Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development? a. A 44 year old prescribed IV antibiotics for pneumonia b. A 26 year old who is bedridden with a fractured leg c. A 65 year old with hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker

ANS: C Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk.

A nurse assesses a young female client who is prescribed tazarotene. Which question should the nurse ask prior to starting this therapy? a. "Do you spend a great deal of time in the sun?" b. "Have you or any family members ever had skin cancer?" c. "Which method of contraception are you using?" d. "Do you drink alcoholic beverages?"

ANS: C Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects. Strict birth control measures must be used during therapy. The other questions are not directly related to this medication.

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. "I will keep dry bandages on the wound and change them when drainage appears." b. "I will shower instead of taking a bath in the bathtub each day." c. "If the dressing is dry, I can sit or sleep anywhere in the house." d. "I will clean exposed household surfaces with a bleach and water mixture."

ANS: C The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.)

Assess all mucous membranes every 4 to 8 hours Listen to lung sounds and monitor for cough Monitor the venous access device appearance hourly Take and record vital signs every 4 to 8 hours

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a. "The wound edges have been approximated and stitched together." b. "The wound was stapled together after an infection was cleared up." c. "The wound is an open cavity that will fill in with granulation tissue." d. "The wound was contaminated by debris and can't be closed at all."

ANS: C Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention. A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

13. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C)

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

9. A nurse is triaging clients in the emergency department. Which client would be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) d. A 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.

3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

1. An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care? a. Primary health care provider b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

1. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

8. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted in picture: (Prominent veins on chest (Vena Cava Syndrome)). What action is most important?

Assess blood pressure and pulse

2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

1. The nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing maximum protection against infection d. Regulating the process of self-tolerance

ANS: C Immunity and Inflammation working together are critical to maintaining health, preventing disease, and repairing tissue damage. When all the different parts and functions of immunity are working well, the adult is immunocompetent and has maximum protection against infection. Working together, their function is not limited to destroying bacteria before damage occurs. They do not prevent the entry of all foreign materials and immunity alone regulates the process of self-tolerance.

7. A nurse cares for victims during a community-wide disaster drill. One of the victims asks, "Why are the individuals with black tags not receiving any care?" How does the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

ANS: C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Victims are not "sacrificed." Telling victims that is important to move on after identifying the expectant dead does not provide an adequate explanation and is callous. Victims are not black-tagged to allow volunteers to give comfort care.

16. A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. "Gabapentin can be used as an antidepressant too." b. "I have no idea why you would be taking this drug." c. "This drug helps treat the pain from nerve irritation." d. "You are at risk for seizures due to fungal infections."

ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants and anticonvulsants such as gabapentin. It is not being used to prevent seizures from fungal infections. If the nurse does not know the answer, he or she would find out for the client.

6. The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.

5. An emergency department manager wants to mitigate the possible acute and chronic stress after mass casualty events in the staff. What action would the manager take? a. Encourage all staff to join a Disaster Medical Assistance Team. b. Instruct all staff members to prepare go bags for all family members. c. Use available resources for broad education and training in disaster management. d. Provide incentives and bonuses for responding to mass casualty events.

ANS: C Research indicates that education and training in disaster management before an incident occurs is associated with improved confidence and better coping after the incident. Go bags are important to maintain for all family members but would not be effective in mitigating stress. A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. Incentives and bonuses will not help mitigate stress.

8. A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Signs and symptoms of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse would monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

4. A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the primary health care provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C Since this client's CD4+ cell count is so low, he or she may have energy, or the inability to mount an immune response to the TB test. The client also appears to have progressed to HIV-III. The nurse would first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the primary health care provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.

2. When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

13. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my primary health care provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."

ANS: C Teaching to prevent altitude-related illness would include descending when symptoms start, staying hydrated, and taking acetazolamide, which is commonly used to prevent and treat acute mountain sickness. The nurse would teach the client to sleep at a lower elevation.

11. A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does the nurse anticipate has the highest need for further assessment and referral? a. Client who is still trying to locate relatives who are missing b. Family awaiting the ability to travel out of state for temporary housing c. Client with a score of 48 on the Impact of Event Scale-Revised (IES-R) d. Client who has trouble sleeping and who startles easily

ANS: C The IES-R is an assessment tool is a 22-item self-administered questionnaire that scores individuals on signs and symptoms of acute stress disorder or posttraumatic stress disorder. A score of 33 or higher out of 88 is a positive finding and this client would be referred a psychiatrist or other licensed mental health care provider. The nurse would administer the assessment to the client with difficulty sleeping after ensuring he or she can read at the 10th grade level, which is the reading level of the tool. The other two clients do not show evidence of particular needs for referral beyond what is usually provided in a natural disaster.

17. A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide? a. "The client is too dehydrated for moist-sounding lungs." b. "The client hasn't started having any bronchospasm yet." c. "Lung edema is in the interstitial tissues, not the airways." d. "Clients with ARDS usually have clear lung sounds."

ANS: C The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information

16. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client's 24-hour fluid balance.

ANS: C The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.

3. An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

15. An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

ANS: C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

15. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action would the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for postincident crisis support. d. Talk individually with staff members.

ANS: C The staff may be suffering from stress related to the multiple traumas and needs to have crisis support. A crisis support team can assist the staff with developing appropriate coping methods. Speaking with staff members individually does not provide the same level of support as trained health care providers who can offer emotional first aid. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as formalized crisis support.

6. A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client says, "I can't believe that my spouse is gone and I am left to raise my children all by myself." How would the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation.

8. An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.) a. Ataxia b. Confusion c. Crackles in both lung fields d. Decreased level of consciousness e. Persistent dry cough f. Reports "feeling hung over"

ANS: C, E Signs and symptoms of high-altitude pulmonary edema (HAPE) include poor exercise tolerance, prolonged recovery time after exertion, fatigue, and weakness that progresses to a persistent dry cough and cyanosis of lips and nail beds. Crackles may be auscultated in one or both lung fields. A late sign of HAPE is pink, frothy sputum. Ataxia and confusion or decreased level of consciousness are seen in HACE—high-altitude cerebral edema. Acute mountain sickness produces a syndrome similar to an alcohol-induced hangover

3. A nurse assesses a client who is prescribed furosemide for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.

4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

ANS: D The most important nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Client's with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? a. "Take monthly photographs of it so you can document any changes." b. "Wash daily with warm water and gentle soap to prevent infection." c. "Keep the lesion covered with a bandage and triple antibiotic ointment." d. "Please make an appointment to be seen here as soon as possible."

ANS: D A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer.

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? a. "I will shower daily using a super-fatted soap." b. "I can try taking a bath with colloidal oatmeal." c. "I will pat my skin dry instead of rubbing it with a towel." d. "I will be careful to keep my nails filed smoothly."

ANS: D The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury.

A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing

ANS: D This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.

3. A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath has a threat to oxygenation and is the most critical. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II (urgent, yellow tag); these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent (class III, green tag).

2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How would the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."

ANS: D Clients would be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

A client receiving radiation therapy reports severe skin itching and irritation. What action does the nurse delegate to assistive personnel? (Select all that apply.)

Apply approves moisturizers tot he skin Bathe the client using mild soap Help the client pat the skin dry after a bath Make sure no clothing is rubbing he site

11. A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client's temperature every 4 hours.

ANS: D Fever and chills indicate systemic toxicity, which can lead to hemolytic anemia, thrombocytopenia, DIC, and death. Assessing for a fever would indicate this complication. All other symptoms are normal for a brown recluse bite and would be assessed, but they do not provide information about complications from the bite

21. A new nurse asks for an explanation of "refractory hypoxemia." What answer by the staff development nurse is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

7. The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T-cells c. Natural killer cells d. Regulator T-cells

ANS: D Regulator T-cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic T-cells are effective against self cells infected by parasites such as viruses or protozoa

14. A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

ANS: D Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent

4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask nursing staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D The ED charge nurse would direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they would not be assigned to the most critically ill or injured clients. The hospital incident commander's role is to take a global view of the entire situation and facilitate patient movement through the system, while bringing in personnel and supply resources to meet patient needs. The medical command physician would kept the incident commander informed about victims and capacity of the ED.

2. While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine and apply ice. d. Administer an epinephrine autoinjector and call 911.

ANS: D The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. The nurse would call 911 would immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it would be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis, although the nurse would remove the stinger as soon as possible after administering the autoinjector.

11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury

8. A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food. b. Has decreased oral discomfort. c. Eats 90% of meals and snacks. d. Has a weight gain of 2 lb (1 kg)/1 mo.

ANS: D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients. Choosing high-protein food is important, but only if the client eats and absorbs the nutrients.

20. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation

ANS: D This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client's oxygen during activity. d. Pace activities, allowing for adequate rest.

ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse would not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity.

10. A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Conduct frequent neurologic assessments. c. Conduct frequent respiratory assessments. d. Initiate Protective Precautions.

ANS: D Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis but poses only a rare threat to immunocompetent individuals The nurse would perform ongoing neurologic assessments. Contact and Protective Precautions are not needed. Good respiratory assessments are important to the client, but toxoplasmosis will demonstrate neurologic signs and symptoms.

10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.

20. A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

ANS: D, E Due to the high rate of suicide among older adults, a nurse would assess all older adults for depression and suicide. The nurse would also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)

Absorptive atelectasis Combustion Dried mucous membranes Toxicity

A client has received several doses of midazolam. The nurse assesses the client to be difficult to arouse with respirations of 6 breaths/min. What actions by the nurse are most important? (Select all that apply.)

Administer oxygen per protocol. Ensure suction is working Transfer the client to intensive care.

14. A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?

Administers bisphosphonates as prescribed.

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?

Airway patency

A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?

Allowing a very tired client to skip oral hygiene and sleep

4. A nurse is assessing clients on a med surg unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?

Anxious client who has tachypnea.

6. A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.)

Calculate pulse pressure with each blood pressure reading. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.

1. A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer.

Call the client at home the next day to review teaching.

4. A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding the most common causes of death for these clients is which of the following? (Select all that apply.)

Cardiovascular impairment Chronic kidney disease

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

Check that consent is on the chart. Ensure that the client has an armband on Have the client help mark the surgical site Allow the client to use the toilet before giving sedation Assess the client for fall risks.

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?

Client is able to swallow own secretions without drooling.

1. The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.)

Clotting abnormalities from thrombocythemia Increased risk of infection from white blood cell deficits Nutritional deficits such as early satiety and cachexia Potential for reduced gas exchange Various motor and sensory deficits Increased risk of bone fractures

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)

Cognition Dexterity Range of motion Vision Upper arm range of motion

A nurse assesses a client who has a nasal fracture. The client reports constant nails drainage, a headache, and difficulty with vision. What action would the nurse take next?

Collect the nasal drainage on a piece of filter paper

15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?

Connects the client to a cardiac monitor.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the primary health care provider about a dietitian referral.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first?

Contact the primary health care provider and prepare for intubation.

The nurse is caring for clients on the medical surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

Correctly identifying the client prior to a blood transfusion

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

Create a communication system Try loose-fitting shirts with collars Wear fashionable scarves

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?

Dangle the client on the bedside before ambulating.

A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.)

Decreased cardiac output Decreased oxygenation Frequent nocturia Mobility alterations Slower reaction times

A client is having a catheter places to deliver chemotherapy beads into a liver tumor via the femoral artery. Which action by the nurse is most important?

Ensuring that informed consent is on the chart

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare administer?

Epoetin Alpha

A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?

Explain that xerostomia may be a permanent side effect.

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best?

Gather sterile nonadherent dressings.

21. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Gently inquire about advance directives.

6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?

Help the family show other ways to demonstrate love and caring.

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

Hemoglobin: 7.8 mg/dL (78 mmol/L) pH: 7.68 Potassium: 2.9 mEq/L (2.9 mmol/L)

A nurse us caring for clients with electrolyte imbalances on a medical surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.)

Hyperkalemia-salt substitute Hyponatremia-heart failure Hypernatremia-hyperaldosteronism Hypocalcemia-diarrhea Hypokalemia-loop diuretics

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.)

Hypertension Stroke Weight gain Diabetes Cognitive deficits Pulmonary disease

4. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

Hypokalemia—muscle weakness with respiratory depression Hypermagnesmia-bradycardia and hypotension Hyponatremia-decreased level of consciousness Hypomagnesmia-hyperatice deep tendon reflexes Hypernatremia-weak peripheral pulses

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best?

Notify the primary health care provider.

A nurse assesses a client who is 6 hours post surgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.)

Observe for clear drainage Assess for signs of bleeding Watch the client for frequent swallowing Ask the client to open his or her mouth

13. The nurse assesses the client using the device pictured below to deliver 50% O2: (Venturi mask) The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?

Immediately increase the flow rate

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.)

Increased pulse rate Distended neck veins Skeletal muscle weakness Visual disturbances

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.)

Infection prevention Thromboembolism prevention Correct hair removal

10. A client has a platelet count of 9800/mm3 (9800 x109/L). What action by the nurse is most appropriate?

Instruct the client to call for help to get out of bed

A nurse is caring for several clients in the morning prior to surgery. Which medications taken by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.)

Insulin Phenytoin Metoprolol Warfarin Prednisone

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that the outcomes for clients safety with oxygen therapy are being met?

Intact skin behind the ears

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.)

Liver biopsy: diagnostic Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive Body contouring: cosmetic

4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.)

Morbidly obese client Client who smokes Client with severe heart failure Wheelchair-bound client

A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer?

Naloxone 0.4 to 2 mg

The nurse is teaching a client with obstructive sleep apnea (OSA) about he prescribed CPAP. What information does the nurse include? (Select all that apply.)

Once the delivery mask is adjusted, do not loosen the straps. The CPAP provides pressure that holds your upper airways open. The humidification increases the risk of fungal infections. Be patient when first using the system, it can be frustrating at first.

A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.)

Oral mucosa is gray or dark brown Pain when drinking grapefruit juice Oral lesions that are over 2 weeks old Changes in the patients voice quality

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority?

Participating in hand-off report

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

Phase I requires intensive care unit monitoring. Phase II ends when the client is stable and awake. Vital signs may be taken only once a day in phase III.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L (2.9 mmol/L)

A nurse is caring for several clients at risk for fluid imbalances. Which lab results are paired with the correct potential imbalance? (Select all that apply.)

Potassium: 5.4 mEq/L (mmol/L): Dehydration Osmolarity: 250 mOsm/L: Overhydration Hematocrit: 68%: Dehydration Magnesium: 0.8 mg/dL: Dehydration

A nurse cares for a client who has a serum potassium of 6.5 mEq/L and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?

Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best?

Read the policy on handling radioactive excreta.

16. A nurse is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the nurse to notify the primary health care provider immediately?

Red, warm, swollen calf

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.)

Reports of palpitations Skeletal muscle weakness Tall, peaked T waves on ECG

19. A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important?

Request a prescription for cardiac monitoring

A nurse is caring for a client admitted for Non-Hodgkins lymphoma ands chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is the most important?

Request an order for serum electrolytes and uric acid.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met?

The client has joined a book club that meets at the library.

A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention?

Securing the drain's safety pin to the sheets

A nurse assess a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complication will the nurse assess? (Select all that apply.)

Serum Potassium of 5.4 mEq/L Blood osmolality of 250 mOsm/kg

15. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first?

Serum potassium of 2.8 mEq/L (2.8 mmol/L)

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

Sets the IV pump to deliver 30 mEq of potassium an hour.

A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next?

Signs of oxygenation

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?

Stay with the client and have someone else call the primary health care provider immediately.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

Stridor Eye pain

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that the treatment is improving the client's hypokalemia? (Select all that apply.)

Strong productive cough Active bowel sounds

A nurse teaches a client who has a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration?

Swallow twice while bearing down

12. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

Teaching measures to prevent scalp injury

The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next?

Temperature

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

A. nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse?

Tying a square knot at the back of the neck

1. The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

Type I—examples include hay fever and anaphylaxis. Type III—immune complex deposits in blood vessel walls. Type IV—examples are poison ivy and transplant rejection.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate?

Wear personal protective equipment when handling the medications.

9. The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?

a. "I will be careful if I need enemas for constipation."

1. A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?

b. 21%