Exam 1 and Conversions

Risk Factors of impaired tissue integrity

- Advanced age - Genetics - Prolonged bowl and/or urinary incontinence - Immobility or decreased mobility - Alteration in level of consciousness - Malnutrition - Chronic disease (DM, PVD)

1 Tbsp = ___ mL

1 Tbsp = 15 mL

1 Tbsp = ___ tsp

1 Tbsp = 3 tsp

1 g = ___ mg

1 g = 1000 mg

1 kg = ___ g

1 kg = 1000 g

1 kg = ___ lbs

1 kg = 2.2 lbs

1 mL = ___ cc

1 mL = 1 cc

1 tsp = ___ mL

1 tsp = 5 mL

1 L = ___ mL

1000 mL

The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? A: "It stimulates the heart to beat in a normal rhythm." B: "It protects the heart from atherosclerotic changes." C: "It provides the heart with oxygenated blood." D: "It protects the heart from infection."

A: "It stimulates the heart to beat in a normal rhythm." The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia? A: High Fowler B: Left side-lying C: Right side-lying D: Flat on the back

A: High Fowler A client experiencing autonomic dysreflexia would immediately be placed sitting up to lower blood pressure. Left side-lying, right side-lying, and flat-on-the-back positions would not lower blood pressure.

The nurse observes vaginal packing protruding from the client's vaginal vault after radium implants for cervical cancer were inserted. Which rationale supports the need for the nurse to contact the client's primary health care provider immediately? A: The radioactive packing will injure healthy tissue. B: Removal of the packing will prevent excessive blood loss. C: Radium exposure to the environment diminishes the effectiveness. D: Removal of the packing minimizes life-threatening contact with the radiation.

A: The radioactive packing will injure healthy tissue. During the procedure, vaginal packing maintains the radium implant in the correct location; correct placement minimizes the effect on healthy tissue. There should not be active bleeding with a radium implant; there is an expectation of cellular sloughing. Although exposure to the radioactive packing damages healthy tissue, it is not life threatening.

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? A: Tissue ischemia B: Brain malformations C: Intestinal blockage D: Cardiac dysrhythmia

D: Cardiac dysrhythmia Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

Which intervention would provide comfort to the client experiencing alcohol toxicity? A: Dim the lights. B: Use distraction. C: Offer activities. D: Stay with the client.

D: Stay with the client. Agitation and anxiety are common in clients experiencing alcohol toxicity. Staying with the client as much as possible will help decrease their anxiety and provide the opportunity to reorient them as needed. Dimming the lights may place the client at risk for injury due to their impaired judgment and lack of coordination. Distraction and activities are not appropriate nursing interventions at this time.

Epidermis

Outermost layer of skin, thinnest, and without blood supply

Nutritional supplements needed for healing

Protein Vitamin A Vitamin C

Mobility

The ability of an individual to perform purposeful physical movement of the body.

Tissue Integrity

The intactness of the structure and function of the integument (skin and subcutaneous tissue) and mucous membranes.

Hypertension

high blood pressure

Risk factors for impaired mobility

- Age: older adults - Acute and chronic disease processes - Pain: acute/chronic - Injury/trauma - Neurological/cognitive impairment

Interrelated concepts of mobility

- Comfort - Sensory perception - Elimination

Hypertension Risk Factors

- Family history - Smoking - African American - Hyperlipidemia - Overweight/obese - Above the age of 60/postmenopausal - Excessive sodium and caffeine intake and constant stress

Assessment of mobility

- Health history and medications - Focused musculoskeletal assessment including ROM, posture, and ability to perform ADL's. - Lab and diagnostic testing including radiology, serum lab, and nuclear med.

Assessment of Tissue Integrity

- Health history and medications - Focused assessment including skin risk assessment (Braden scale) and skin/wound assessment. - Lab and diagnostic testing: serum albumin and prealbumin levels, WBC, CT scans/MRI, and Ultrasound.

Interrelated concepts of impaired tissue integrity

- Immunity - Nutrition - Mobility

Physiological consequences of impaired tissue integrity

- Localized (cellulitis) or systemic (sepsis) infections - Hemorrhage - Dehiscence - Evisceration - Loss of mobility - Pain

Factors affecting wound healing

- Oxygenation and tissue perfusion - Diabetes - Nutrition - Age - Infection

Health promotion strategies to prevent impaired tissue integrity

- Perform proper hand hygiene - Implement proper nutrition - Perform daily skin inspection - Keep skin clean and dry - Moisturize the skin when needed to prevent excessive dryness. - Protect skin from sun

Health promotion strategies to prevent impaired mobility

- Primary prevention: maintain optimal function, exercise, weight management, and nutrition. - Decrease risk for falls/improve safety - Optimize skin integrity

Nursing interventions for impaired mobility

- ROM - Pain management - Patient education on ambulatory devices - Collaborative care to prevent complications with other body systems.

Physiological consequences of impaired mobility

- Safety: recognition of fall risk - Tissue integrity - Decreased ROM - Perfusion disorders: respiratory and circulatory complications.

1 mg = ___ mcg

1 mg = 1000 mcg

1 oz = ___ Tbsp

1 oz = 2 Tbsp

1 oz = ___ mL

1 oz = 30 mL

The nurse teaches exercises to a client with a long leg cast. Which client statement indicates an accurate understanding of when to perform isometric exercises? A: "Ten times each waking hour" B: "Before meals and at bedtime" C: "At each physical therapy session" D: "Each evening when watching television"

A: "Ten times each waking hour" Routine frequent exercising, such as ten times each waking hour, is the optimal way to promote circulation and minimize disuse syndrome. "Before meals and at bedtime" is too infrequent and may contribute to the development of circulatory complications and disuse syndrome. "At each physical therapy session" is too infrequent. The client must continue physical therapy at home. "Each evening" is too infrequent.

Which physiological characteristics of newborns affect medication dosage considerations? Select all that apply. One, some, or all responses may be correct. A: A newborn's less regulated body temperature B: Immature liver and kidneys C: Thick and less permeable skin D: Lungs with weaker mucous barriers E: Bacteria-killing acid in the stomach

A: A newborn's less regulated body temperature B: Immature liver and kidneys D: Lungs with weaker mucous barriers The body temperature of newborns is less regulated, and dehydration occurs easily. This characteristic affects the medication dosage consideration in newborns. Metabolism and excretion are impaired in pediatric clients because of an immature liver and kidneys. The lungs in pediatric clients have weak mucous barriers; this characteristic also affects the dosage considerations in newborns. A newborn's skin is thin and more permeable. The newborn has no acid in the stomach to kill the bacteria; therefore, medication absorption from the gastrointestinal tract is affected, thus affecting dosage considerations

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats/minute. Which action is indicated? A: Administer amiodarone. B: Administer epinephrine. C: Assist with insertion of a pacemaker. D: Administer atropine.

A: Administer amiodarone. Amiodarone suppresses ventricular activity; therefore it is used for treatment of premature ventricular complexes (PVCs) and ventricular tachycardia. It works directly on the heart tissue and slows the nerve impulses in the heart. Epinephrine hydrochloride is not used for ventricular tachycardia (VT) with a pulse and may even precipitate ventricular fibrillation. A pacemaker is used for symptomatic bradycardia and heart blocks. Atropine is used to treat bradycardia.

When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? A: Attach the cardiac monitor. B: Auscultate the heart sounds C: Check the intravenous fluid rate. D: Assess alertness and orientation.

A: Attach the cardiac monitor. Because fatal dysrhythmias may occur in the first hours after myocardial infarction, cardiac monitoring is a priority. The nurse will also do auscultation of the heart, but changes in heart sounds are not expected with ACS and PCI. Checking the intravenous line for patency and correct infusion rate is also important, but would be done after establishing cardiac monitoring. Neurological status would be assessed, but changes in neurological status are not expected after PCI, which does not require general anesthesia.

Which finding does the nurse expect when checking the vital signs of a client in the early postpartum period? A: Bradycardia with no change in respirations B: Tachycardia with a decrease in respirations C: Increased basal temperature with a decrease in respirations D: Decreased basal temperature with an increase in respirations

A: Bradycardia with no change in respirations In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth. Bradycardia is more likely than tachycardia, and respirations generally are unchanged. The temperature may rise slightly, but usually respirations are unchanged.

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction? A: Circulating nurse B: Surgical assistant C: Registered nurse first assistant D: Certified registered nurse anesthetist

A: Circulating nurse The circulating, or nonsterile, nurse would sit with the client to provide comfort during induction. The surgical assistant and registered nurse first assistant will be assisting the surgeon during the procedure and will be scrubbed and sterile. The certified registered nurse anesthetist will be focused on providing medications to the client and cannot sit with the client during induction.

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply. One, some, or all responses may be correct. A: Dry cough B: Chest pain C: Hemoptysis D: Shortness of breath E: Fever greater than 100.4°F (38°C)

A: Dry cough D: Shortness of breath E: Fever greater than 100.4°F (38°C) Between 2 and 7 days after the onset of SARS, which is caused by a coronavirus, clients exhibit a dry cough. SARS is an acute viral respiratory infection that results in respiratory signs and symptoms, including difficulty breathing and shortness of breath. SARS, a viral infection, generally begins with a fever greater than 100.4°F (38°C), headache, and muscle weakness. Although clients may exhibit sinus tachycardia, chest pains are not a typical symptom associated with SARS. The cough associated with SARS is nonproductive, and hemoptysis does not occur.

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? A: Elevated blood pressure B: Bounding pedal pulses C: Night blindness D: Reflux disease

A: Elevated blood pressure Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

The nurse understands which anesthetic medication is commonly used for short procedures on pediatric clients? A: Fentanyl B: Morphine C: Meperidine D: Hydromorphone

A: Fentanyl Fentanyl is recommended for short procedures on pediatric clients. For long procedures in which pain is anticipated even after the procedure, morphine should be administered. Meperidine and hydromorphone are used to achieve mild to moderate sedation in pediatric clients.

Which action would the nurse take when using a mechanical lift device to transfer a client? A: Fold the client's arms across the chest. B: Place the top of the sling below the client's scapulae. C: Wait until a prescription is written to use a mechanical lift. D: Lift the sling at least 12 inches (30.5 cm) above the mattress.

A: Fold the client's arms across the chest. Folding the arms across the chest maintains both arms in a safe position during the transfer. During a safe transfer, the sling should extend from above the scapulae to the knees to provide appropriate support. The use of a mechanical lift is an independent function of the nurse. Raising the lift so that the sling is at least 12 inches (30.5 cm) above the mattress height is unsafe; during the transfer, the sling should be raised just high enough (3-4 inches [7.6-10.2 cm]) to clear the mattress.

Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema? A: Furosemide B: Chlorothiazide C: Spironolactone D: Acetazolamide

A: Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium; is available for intravenous administration; and is more effective than chlorothiazide, spironolactone, and acetazolamide. Although it is used in the treatment of edema and hypertension, chlorothiazide is not as efficacious as furosemide. Spironolactone is a potassium-sparing diuretic; it is less efficacious than thiazide diuretics. Acetazolamide is used in the treatment of glaucoma to lower intraocular pressure.

Which action is likely to help prevent pressure injuries for a client who has paraplegia? A: Inspecting the skin every day B: Providing a rubber seat cushion C: Massaging body lotion over reddened areas D: Applying a heating pad to bony prominences

A: Inspecting the skin every day Because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas or lesions is necessary so that treatment can be initiated quickly. Providing a rubber cushion on which to sit may contribute to circumscribed pressure, which can lead to skin breakdown. Rubber promotes perspiration, which increases the risk of pressure ulcers. Massage of reddened areas may cause further damage and should be avoided. Because sensation may be compromised, a heating pad should not be used.

A client with type 1 diabetes has dry, hot, flushed skin; a fruity odor to the breath; and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? A: Ketoacidosis B: Somogyi phenomenon C: Hypoglycemic reaction D: Hyperosmolar nonketotic coma

A: Ketoacidosis Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

Which nursing action would be implemented after a client has a lumbar puncture? A: Maintaining the client in the supine position for several hours B: Encouraging the client to ambulate every hour for at least 6 hours C: Keeping the client in the Trendelenburg position for at least 2 hours D: Placing the client in the high-Fowler position immediately after the procedure

A: Maintaining the client in the supine position for several hours Staying flat may help prevent spinal fluid leakage and post procedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat.

A client experiences a lateral crushing chest injury. Assessment findings include obvious right-sided paradoxical motion of the chest and multiple rib fractures, resulting in a flail chest. The nurse would monitor the client for which complication? A: Mediastinal shift B: Tracheal laceration C: Open pneumothorax D: Pericardial tamponade

A: Mediastinal shift Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which are considered within normal range for this client? Select all that apply. One, some, or all responses may be correct. A: Oral temperature of 98.2°F (36.8°C) B: Apical pulse of 88 beats/min and regular C: Respiratory rate of 30 breaths/min D: Blood pressure of 116/78 mm Hg while in a sitting position E: Oxygen saturation of 92%

A: Oral temperature of 98.2°F (36.8°C) B: Apical pulse of 88 beats/min and regular D: Blood pressure of 116/78 mm Hg while in a sitting position The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 breaths/min, and oxygen saturation level should be 95%.

Which nursing interventions would the nurse include in the plan of care for a client after a hip replacement? (Select all that apply). A: Place a pillow between the client's legs. B: Require the client to sit in an armless chair. C: Cross the client's legs at the ankles and knees. D: Require the client to use an elevated toilet seat. E: Keep the client's hip in a neutral, straight position

A: Place a pillow between the client's legs. D: Require the client to use an elevated toilet seat. E: Keep the client's hip in a neutral, straight position A client who has undergone hip replacement needs help while standing; therefore, the nurse should not have the client sit in an armless chair because the client may experience discomfort and difficulty when standing. Crossing the client's legs at the ankles and knees after a hip replacement may cause pain and venous stasis, promoting thrombus formation. Using a pillow between the legs provides comfort and helps keep the joint abducted. Use of an elevated toilet seat allows for easy movement and prevents hip dislodgement. Keeping the client's hip in a neutral, straight position prevents pain and discomfort and hip dislocation.

The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next? A: Provide perineal care. B: Turn and position the client. C: Give a complete bed bath. D: Document the bowel movement.

A: Provide perineal care. Providing perineal care helps preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. A: Providing oxygen B: Assessing vital signs C: Obtaining a 12-lead EKG D: Drawing blood for cardiac enzymes E: Auscultating heart sounds F: Administering nitroglycerin

A: Providing oxygen B: Assessing vital signs C: Obtaining a 12-lead EKG D: Drawing blood for cardiac enzymes E: Auscultating heart sounds F: Administering nitroglycerin The nurse would provide oxygen to a client with chest pain, as the heart may be getting insufficient oxygen as a result of occluded coronary vessels. The nurse would also assess the client's vital signs, obtain a 12-lead EKG, and auscultate heart sounds to determine rhythm changes related to cardiac ischemia. The nurse would need to draw blood for evaluation of cardiac enzymes. Changes in the levels of these enzymes (including troponin, creatine kinase, and myoglobin) can indicate damage to heart tissue. Nitroglycerin is administered to promote coronary vasodilation.

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? A: Stop the blood transfusion and infuse saline. B: Administer the prescribed antipyretic. C: Obtain a prescription for an antihistamine. D: Notify the blood bank about the symptoms.

A: Stop the blood transfusion and infuse saline. Fever, chills, and low back pain indicate an acute hemolytic reaction, which is potentially life threatening; discontinuing the transfusion immediately and infusing saline limits kidney damage. Although the client has a fever, administering an antipyretic before stopping the transfusion would allow the transfusion reaction to continue. The client's safety must be addressed first. Obtaining a prescription for an antihistamine may be done after stopping the transfusion and infusing saline. Although the blood bank generally is notified if a reaction occurs, this would be done after stopping the transfusion.

According to triage based on tier levels, which client conditions would receive higher priority? (Select all that apply). A: Stroke B: Skin rash C: Active hemorrhage D: Respiratory distress E: Chest pain with diaphoresis F: Displaced or multiple fractures

A: Stroke C: Active hemorrhage D: Respiratory distress E: Chest pain with diaphoresis Clients presenting with signs of a stroke, active hemorrhage, respiratory distress, or chest pain with diaphoresis should be triaged under the emergent tier level because the conditions are life threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately life threatening.

A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? A: Suction the tracheostomy. B: Change the tracheostomy tube. C: Readjust the tracheostomy tube and tighten the ties. D: Perform a complete respiratory assessment.

A: Suction the tracheostomy. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem-solving may require readjustment of the tracheostomy tube and ties or a health care provider changing the tracheostomy tube.

Which side effect would the nurse assess for after epinephrine is administered to an infant with severe bronchospasms? A: Tachycardia B: Hypotension C: Respiratory arrest D: Central nervous system depression

A: Tachycardia Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.

The nurse is reviewing a plan of care for a client who experienced a traumatic amputation of a leg the previous day. Which intervention listed on the plan is of lowest priority? A: Teaching residual limb care B: Monitoring hemoglobin levels C: Maintaining the compression dressing D: Using therapeutic interviewing techniques

A: Teaching residual limb care Teaching residual limb care is not a priority at this point. The client is too traumatized to learn. It will assume priority as the client's recovery progresses. The nurse must closely monitor the hemoglobin level, because blood loss is a major problem. Maintaining a pressure dressing helps prevent edema and bleeding and helps shape the residual limb for a prosthesis. The client has experienced a major life event; the nurse will need to be empathetic and use interviewing skills to encourage expression of feelings.

A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. The nurse would expect to teach the client about which condition? A: Tinea pedis B: Tinea cruris C: Tinea corporis D: Tinea unguium

A: Tinea pedis Tinea pedis is a fungal infection with an itching sensation associated with pain. It is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering. Tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area. Tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

Which describes the focus of hospice care? A: To ease the pain from illness B: To provide curative treatment C: To assist with activities of daily living D: To adapt to the limitations due to an illness

A: To ease the pain from illness The focus of hospice care is palliative care to ease the pain caused by the illness. It is a system of family-centered care that allows clients to live at home with dignity. Hospice care does not provide curative treatment. The health care team follows an individualized plan of care for the client. Assisted living facilities offer long-term care for the older client in settings with a homelike environment. These facilities assist the client with activities of daily living. Rehabilitation facilities provide restorative care that helps the client adapt to the limitations caused by the illness.

Suspected deep tissue pressure injury

Area of intact skin that is purple. maroon, or blood filled blister. True depth of tissue damage is not readily apparent. Wound can progress rapidly.

The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? A: "Central perfusion is monitored only by the physician." B: "Central perfusion involves the entire body." C: "Central perfusion is decreased with hypertension." D: "Central perfusion is toxic to the cardiac system."

B: "Central perfusion involves the entire body." Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body's ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

Which intervention improves client satisfaction? A: Recording the vital signs and leaving the room B: Adjusting the bed and asking if the client is comfortable C: Leaving the door of the room open while attending to the client D: Telling the client that the primary health care provider will visit soon

B: Adjusting the bed and asking if the client is comfortable

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? A: Surgery B: Comfort C: Education D: Motivation

B: Comfort Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.

Which is the rationale for administering oxygen by way of a nasal cannula for the child diagnosed with acute laryngotracheobronchitis (croup)? A: Congeals mucous secretions and relieves dyspnea B: Decreases the effort required for breathing and permits rest C: Triggers the cough reflex and facilitates expectoration of mucus D: Liquefies mucous secretions and makes them easier to expectorate

B: Decreases the effort required for breathing and permits rest Administering oxygen by way of nasal cannula limits the energy required for breathing; this allows the child to conserve energy that can be used for fluid and nutrient intake. Congealed mucus will obstruct air passageways and increase respiratory distress. Oxygen administration does not trigger the cough reflex. Oxygen administration through a nasal cannula will have a drying effect.

Which action would the nurse take to decrease risk for ventilator-associated pneumonia (VAP) in a client who is receiving mechanical ventilation? A: Suction the client on a regular schedule. B: Elevate the head of the bed to at least 30 degrees. C: Schedule daily changes of the ventilator tubing. D: Maintain continuous sedation during ventilator use.

B: Elevate the head of the bed to at least 30 degrees. Elevating the head of the bed to 30 to 45 degrees helps reduce aspiration and decreases incidence of VAP. Suctioning is done only when assessment data indicate that it is necessary. Changes of ventilator tubing increase the risk for VAP, and tubing changes are recommended only when there is visible soiling of the tubing. Sedation should be interrupted at least daily to allow evaluation of client respiratory effort and possible readiness for extubation.

Which action would the nurse take first for a client who just had a transurethral resection of the prostate and reports pain in the operative area? A: Administer the prescribed analgesic. B: Inspect the drainage tubing for patency. C: Encourage intake of fluids to dilute urine. D: Take a full set of vital signs

B: Inspect the drainage tubing for patency. Pain after a prostatectomy may indicate retention of urine as a result of blocked drainage tubes or infection, or it may be an expected response to surgery. The possibility of any complication must be investigated. Analgesics can be administered after the cause of pain is investigated. Encouraging fluids without a patent drainage tube will increase pressure and discomfort; assessment should occur before implementation. The need to measure vital signs is dependent upon the analgesic prescribed; assessing the cause of pain takes priority.

For which physiological condition would the nurse teach an older adult client about the use of isometric exercises? A: Kyphosis B: Muscle atrophy C: Decreased bone density D: Decreased range of motion (ROM)

B: Muscle atrophy Muscle atrophy occurs due to muscular weakness; isometric exercises can help increase muscular strength. Introducing the client to proper body mechanics and instructing the client to sit in supportive chairs with arms reduces kyphosis. Teaching safety tips to prevent falls and reinforcing the need to exercise reduces complications associated with decreased bone density. The nurse should assess the client's ability to perform activities of daily living and mobility in a client with a decreased ROM.

The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? A: Mental alertness B: Perfusion C: Pain D: Reaction to medications

B: Perfusion Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider? A: Apical heart rate 55 beats per minute B: Premature ventricular contractions C: Serum potassium level 5 mEq/L (5 mmol/L) D: Bilateral swelling of the lower extremities

B: Premature ventricular contractions Digoxin toxicity can manifest with premature ventricular contractions (PVCs) or other ventricular dysrhythmias such as ventricular tachycardia or fibrillation. The nurse would communicate the presence of PVCs to the provider and anticipate collaborative actions such as checking digoxin level and potassium level. An apical heart rate of 55 would be reported, but some providers prefer a heart rate of 50 to 60 beats per minute, and no immediate change in treatment would be needed. Hypokalemia can lead to digoxin toxicity, but a serum potassium level of 5 mEq/L (5 mmol/L) would not increase risk for digoxin toxicity. Bilateral swelling of the lower extremities in a client with heart failure indicates a possible need for a change in treatment but is not life threatening.

For which condition is an adult client with a weakened urinary sphincter at risk? A: Bladder distention B: Skin irritation C: Tendency to fall D: Urinary retention

B: Skin irritation The weakening of the urinary sphincter results in involuntary dribbling of urine, which increases the risk of skin irritation and infections. Maintaining thorough hygiene in the perineum area reduces the chance of occurrence of infection or skin rash. The nurse should observe for signs of bladder distention in clients who have a tendency to retain urine. Keeping a bedside light at night is an intervention to prevent night falls in clients who have nocturia. A weakened urinary sphincter will cause loss of urine.

Which topical immunomodulator is used to treat a client with atopic dermatitis? A: Mupirocin B: Tacrolimus C: Clindamycin D: Erythromycin

B: Tacrolimus Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.

A pain scale of 1 to 10 is used by the nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. Which conclusion would the nurse make regarding the client's response to pain medication? A: The client has a low pain tolerance. B: The medication is not adequately effective. C: The medication has sufficiently decreased the pain level. D: The client needs more education about the use of the pain scale.

B: The medication is not adequately effective. The expected effect should be more than a 1-point decrease in the pain level. Whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. There is not sufficient data to determine whether the client needs more education about the use of the pain scale.

Which assessment of the affected leg would the nurse make after a client has an open reduction internal fixation of a fractured hip? A: Femoral pulse B: Toes for mobility C: Condition of the pin D: Range of motion of the knee

B: Toes for mobility Monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this is part of a neurovascular assessment. The femoral artery is not assessed, because it is not distal to the surgical site. No pin is present with an open reduction and internal fixation of a fractured hip. An assessment of range of motion of the knee may cause flexion of the hip, which is contraindicated.

Which assessment would the nurse include when taking the health history of a toddler with an exacerbation of eczema? (Select all that apply). A: Change in appetite B: Wearing cotton clothes C: Exposure to new foods D: Exposure to a viral infection E: Recent contact with someone with eczema

B: Wearing cotton clothes C: Exposure to new foods Eczema is a common manifestation of allergies in the young child and is often related to foods and clothing. Wearing cotton clothing indicates that the parents understand and are trying to minimize their child's allergic reaction. Exposure to new foods is a common trigger for eczema. Appetite does not play a role in the occurrence of eczema. Eczema is an allergic manifestation; it is not contagious.

Open wound

Break in skins surface (abrasion, puncture, surgical incision)

A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? A: "Hypertension happens to everyone sooner or later. Don't be concerned about it." B: "Hypertension can happen from eating a poor diet, so change what you are eating." C: "Hypertension can happen from arterial changes that block the blood flow." D: "Hypertension happens when people do not exercise, so you should walk every day."

C: "Hypertension can happen from arterial changes that block the blood flow." Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patient's diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? A: "Perfusion is a normal function of the body, and I don't have to be concerned about it." B: "Perfusion is monitored by the physician." C: "Perfusion is monitored by vital signs and capillary refill." D: "Perfusion varies as a person ages, so I would expect changes in the body."

C: "Perfusion is monitored by vital signs and capillary refill." The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

A client whose spinal cord was severed in an accident 1 month ago asks the nurse what is causing the severe leg spasms. Which response would the nurse make? A: "You have developed thrombophlebitis, which causes pain." B: "Motor function is returning now that the edema is subsiding." C: "Spinal shock has subsided, and your reflexes are hyperactive." D: "The nerves are regenerating, and your motor function is returning."

C: "Spinal shock has subsided, and your reflexes are hyperactive." Muscles are flaccid during spinal shock but develop spasticity with recovery; these movements are entirely involuntary. Although thrombophlebitis may occur, the client will not have any sensation of pain. Once nervous tissue is transected, it does not regenerate, and paralysis therefore remains. Although edema may be subsiding, motor function will not return if the cord is transected; paralysis remains below the level of the injury.

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do? A: Ask the client to take several deep breaths. B: Instruct the client to cough before suctioning. C: Administer 100% oxygen to the client. D: Change the suctioning equipment to ensure sterility.

C: Administer 100% oxygen to the client. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths or cough or have the strength to do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed.

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which property? A: Analgesic B: Antipyretic C: Anti-inflammatory D: Antiplatelet

C: Anti-inflammatory The anti-inflammatory action of aspirin reduces joint inflammation. Aspirin reduces fever, but this is not the rationale for prescribing it for clients with rheumatoid arthritis. It can relieve pain and prevent abnormal clotting; however, although these effects can be beneficial, these are not the primary reasons that it is prescribed for rheumatoid arthritis.

Which laboratory test would the nurse review for a client suspected to have rheumatoid arthritis? A: Pancreatic lipase B: Bence Jones protein C: Antinuclear antibody D: Alkaline phosphatase

C: Antinuclear antibody An antinuclear antibody test may be positive in clients with autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. Pancreatic lipase is an enzyme that catalyzes the breakdown of lipids; this is a test used to diagnose pancreatic problems. Bence Jones protein is a urine test helpful in diagnosing multiple myeloma. Alkaline phosphatase is a blood test that determines phosphorus activity; it is used in diagnosing liver and biliary tract disorders and identifying periods of active bone growth or metastasis of cancer to bone.

A nurse is creating a plan of care for a client with rheumatoid arthritis who has severe pain and swelling of the hand joints. Which details about range-of-motion exercises would the plan include? A: Passively performing the exercises for the client B: Discontinuing the exercises if the client reports discomfort C: Applying heat or cold before the exercises D: Increasing the vigor of the exercises to restore mobility

C: Applying heat or cold before the exercises Heat and cold applications reduce inflammation and discomfort. Passively performed exercises by the nurse will depend on the client's tolerance. Avoiding exercise will increase the destructive effects of immobility. Exercises are necessary to prevent contractures and permanent joint damage, but they cannot restore mobility that has been lost.

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? A: Answer the client's call light immediately to prevent incontinence. B: Place a waterproof pad under the client to prevent soiling the linens. C: Check the client's buttocks at least every 2 hours and clean after incontinence. D: Offer toileting to the client every 2 hours to prevent incontinence.

C: Check the client's buttocks at least every 2 hours and clean after incontinence. Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instructing the client to call for help with elimination needs is not helpful, because the client is confused and unable to use the call bell. Placing a waterproof pad beneath the client helps prevent soiling of the bed but does not keep feces away from the client's skin and does not prevent skin breakdown. Toileting the client every 2 hours to prevent incontinence is not helpful, because the client is confused and unable to follow commands and has no control over elimination needs.

Twenty-four hours after a penile implant, the client's scrotum is edematous and painful. Which action would the nurse take? A: Assist the client with a sitz bath. B: Apply warm soaks to the scrotum. C: Elevate the scrotum using a soft support. D: Prepare for an incision and drainage procedure.

C: Elevate the scrotum using a soft support. Elevating the scrotum using a soft support increases lymphatic drainage, reducing edema and pain. Assisting the client with a sitz bath and applying warm soaks to the scrotum increase circulation to the area, intensifying edema and pain in this client. Preparing for an incision and drainage procedure is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.

A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch, the client becomes diaphoretic and experiences palpitations. Which probable cause of this response would the nurse recognize? A: Intolerance to fatty foods B: Dehiscence of the surgical incision C: Extracellular fluid shift into the bowel D: Diminished peristalsis in the small intestine

C: Extracellular fluid shift into the bowel Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine ( dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with the dumping syndrome. Dehiscence of the surgical incision is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid; it is unrelated to dumping syndrome. Although peristalsis may be decreased because of surgery, it would not account for the adaptations.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. Which describes the character of this documentation? A: Diminished B: Normal C: Full D: Bounding

C: Full The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected or normal pulse, and a 4+ rating is a bounding pulse.

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which concern is the nurse's priority? A: Loss of skin integrity caused by the burns B: Potential infection as a result of the burn injury C: Inadequate gas exchange caused by smoke inhalation D: Decreased fluid volume because of the depth of the burns

C: Inadequate gas exchange caused by smoke inhalation Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.

When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information? A: Rest pain B: Raynaud phenomenon C: Intermittent claudication D: Phantom limb sensation

C: Intermittent claudication Intermittent claudication is pain that results when the arterial system is unable to provide adequate blood flow to the tissues in the presence of increased demands for oxygen and nutrients during exercise; it is relieved by rest. Rest pain is not a response to exercise; it occurs in the extremities during rest, especially at night. Raynaud phenomenon is intermittent episodes of constricted arteries and arterioles in response to extreme cold or emotional stress, causing pallor, paresthesias, and pain. Phantom limb sensation is the presence of unusual sensations or pain in the removed portion of an amputation.

In which order would the emergency department nurse triage the clients based on the threat to organs? A: Hip fracture B: Minor burns C: Intubated trauma D: Cystitis E: Chest pain resulting from ischemia

C: Intubated trauma E: Chest pain resulting from ischemia A: Hip fracture D: Cystitis B: Minor burns A client with intubated trauma is categorized as emergency severity index 1 (ESI-1), which indicates that the life or organ threat is obvious, and the client needs to be seen immediately. The client with chest pain resulting from ischemia is categorized under the ESI-2, which indicates the organ condition is likely to be life-threatening but is not obvious. The client with a hip fracture is categorized under ESI-3, which describes that the threat to organs is low, and the client can be seen after 1 hour. The client with cystitis is categorized under ESI-4 because there is no threat to life or organs, and the assessment could be delayed. The client with minor burns is categorized under ESI-5 because there is no threat to life or organs and assessment could be delayed.

A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. The nurse would expect to teach the client about which condition? A: Albinism B: Addison disease C: Polycythemia vera D: Methemoglobinemia

C: Polycythemia vera The generalized reddish-blue skin alteration is occurring due to increased overall hemoglobin and may be associated with polycythemia vera. Albinism may found with decreased pigmentation of the skin due to a genetically determined defect of melanocytes. Addison disease may be associated with increased melanin production, which may result in a brown skin discoloration. Cyanosis resulting in a blue discoloration of the skin may signify methemoglobinemia.

A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client? A: Restore the client's health. B: Promote the client's recovery. C: Relieve the client's discomfort. D: Support the client's significant others.

C: Relieve the client's discomfort. Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

A client reports pain, weakness, and numbness in the neck, back, and shoulders after working long hours at a computer. Which condition found in the client's electronic medical record is congruent with those symptoms? A: Bursitis B: Meniscus injury C: Repetitive strain injury (RSI) D: Carpal tunnel syndrome (CTS)

C: Repetitive strain injury (RSI) Repetitive strain injury (RSI) is tiny tears and inflammation of the tendons, ligaments, and muscles due to prolonged force, repetitive movements, or awkward postures. It is common for a client working on a computer to have poor body posture and positioning. Bursitis is inflammation of the bursa, which results from repeated and excessive trauma such as gout, rheumatoid arthritis, and infection. It commonly occurs in the hands, knees, greater trochanters of the hip, shoulders, and elbows. A meniscus injury is a ligament sprain, commonly found in basketball, football, soccer, and hockey players. Carpal tunnel syndrome (CTS) is formed in the ligaments and bones because of compression of the median nerve of the hands.

How would the nurse describe the characteristic gait associated with Parkinson disease when documenting it on the client's health record? A: Spastic B: Steppage C: Shuffling D: Scissoring

C: Shuffling Steps are short and dragging ( shuffling); this is seen with defects of the basal ganglia. Spastic gait, short steps with dragging of foot, is associated with neurogenic causes like cerebral palsy. Steppage gait is when the foot slaps down and is associated with peroneal nerve injury or paralyzed dorsiflexor muscles. Scissoring gait is associated with bilateral spastic paresis of the legs as occurs in cerebral palsy or hemiplegia.

Which clinical finding is associated with a skin assessment of decreased thickness and excessive dryness of the epidermis? A: Skin tears B: Skin cancer C: Skin fragility D: Skin hyperplasia

C: Skin fragility The nurse may assess excessive skin dryness due to decreased epidermal thickness. It is associated with skin transparency and fragility. Skin tears may occur due to the flattening of the dermal- epidermal junction. Decreased mitotic homeostasis in the epidermis may cause skin cancer. Skin hyperplasia may occur due to sun-induced changes that cause a decrease in mitotic homeostasis.

The laboratory values of a client with a new esophageal cancer diagnosis include a hemoglobin of 7 g/dL (70 mmol/L), hematocrit of 25%, and red blood cell (RBC) count of 2.5 million/mm 3 (2.5 × 10 12/L). Which priority goal would the nurse add to the plan of care? A: The client will be free of injury. B: The client will remain pain-free. C: The client will demonstrate improved nutrition. D: The client will maintain effective airway clearance.

C: The client will demonstrate improved nutrition. Based on the presented data, improving nutritional status is the priority at this time. The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also, cancer of the esophagus can cause dysphagia and anorexia. Although maintaining the client's safety is a goal, it is not as high a priority as another concern based on the data provided in the question. The data given do not relate to the presence of pain. The data given do not relate to airway obstruction.

Order of steps in which the assessment of a lesion would be performed. A: Measuring each lesion for height, width, and depth B: Observing for any exudate, odor, amount, and consistency C: Measuring the size of the lesion in centimeters by using a small, clear, flexible ruler D: Collecting information about its color, size, shape, type, grouping, and distribution

D B C A The first step in assessing the lesion is to collect standard information about the lesion. This information includes the color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). The next step is to observe for any exudate, odor, amount, and consistency. After this step, the size of the lesion is measured in centimeters by using a small, clear, flexible ruler. Finally, each lesion is measured for height, width, and depth.

When the clinic nurse is assessing a client with thromboangiitis obliterans (Buerger disease), which finding will be most important to communicate to the health care provider? A: Age 41 years B: Burning leg pain C: Taking daily nifedipine D: Continued tobacco use

D: Continued tobacco use Because thromboangiitis obliterans is strongly associated with tobacco use, the health care provider will need to counsel the client about the importance of tobacco cessation. Thromboangiitis obliterans symptoms are most commonly initially seen in men of less than 45 years. Burning leg pain occurs because inflammation of the small arterioles leads to decreased blood flow to the extremities and would be expected in this client. Calcium channel blockers such as nifedipine are frequently prescribed to improve peripheral perfusion in clients with thromboangiitis obliterans.

A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. Which information would the nurse teach the client? A: Substitute isometric exercises for isotonic exercises. B: Stop the exercises for a day and then resume the exercises. C: Delay doing aerobic exercises until the pain subsides. D: Decrease the time and number of exercise repetitions.

D: Decrease the time and number of exercise repetitions. Exercise should be decreased to a level of tolerance. Isometric exercises promote muscle contraction, not joint movement. The exercise should not be stopped. The purpose of aerobic exercises is to improve cardiovascular functioning, not joint movement; there is no reason to interrupt aerobic exercises if they are tolerated.

A client receiving peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution. Which action would the nurse take? A: Increase the rate of infusion. B: Auscultate the lungs for breath sounds. C: Place the client in a supine position. D: Drain the fluid from the peritoneal cavity.

D: Drain the fluid from the peritoneal cavity. Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration. Additional fluid will aggravate the problem. Auscultation is important, but it does not alleviate the problem. The client should be placed in the semi-Fowler position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? A: Skin that is cool to the touch B: Shrinking of the residual limb C: Absence of phantom limb pain D: Evenly darkened skin of the residual limb

D: Evenly darkened skin of the residual limb Even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit. Cool skin may indicate inadequate tissue perfusion, which may be caused by progression of the disease, inadequate wound healing, or excessive pressure from the prosthesis. Shrinking of the residual limb results in an improper fit. Absence of phantom limb pain is unrelated to a proper fit.

When would the nurse expect the client who has rheumatoid arthritis to experience the most joint pain and stiffness? A: After assistive exercise B: When the room is cool C: During the evening hours D: In the morning on awakening

D: In the morning on awakening Inactivity over an extended time increases stiffness and pain in joints. The client typically has morning stiffness, or gel phenomenon. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The pain is not as severe in the evening as in the morning.

A client has a yellow-orange discoloration in the mucous membranes and sclera. Laboratory results reveal red blood cell hemolysis. Which underlying cause of these findings would the nurse suspect? A: Decreased hemoglobin level B: Increased serum carotene level C: Increased blood flow to the skin D: Increased total serum bilirubin level

D: Increased total serum bilirubin level Increased total serum bilirubin level is associated with the yellow-orange discoloration in the mucous membranes and sclera. A decreased hemoglobin level is the underlying cause for the white skin alteration in anemia or shock. A yellow-orange skin alteration may occur around or near the mouth and on the palms of the hands and soles of the feet with an increased serum carotene level. Increased blood flow to the skin is associated with erythema.

The nurse identifies a nontender 5-cm indurated region on the upper arm of a client with type 1 diabetes. The client says to the nurse, "That is where I give myself insulin shots." The nurse concludes that the nodule is a result of which condition? A: Callus B: An allergy C: An infection D: Lipodystrophy

D: Lipodystrophy Lipodystrophy is a noninflammatory reaction causing localized atrophy or hypertrophy and a localized increase in collagen deposits. Injections of insulin will not cause a horny growth such as a wart or callus. An allergic response will precipitate a localized or systemic inflammatory response. Hyperthermia and localized heat, erythema, and pain are associated with an infection.

Which serum hormone level elevates in response to a client's total serum calcium concentration of 7.9 mg/dL (0.43 mmol/L)? A: Estrogen B: Thyroxine C: Growth hormone D: Parathyroid hormone (PTH)

D: Parathyroid hormone (PTH) The normal range of serum calcium lies between 9 and 10.5 mg/dL (0.5 and 0.55 mmol/L). When total serum calcium concentration levels lower, secretion of PTH increases and stimulates bones to promote osteoclastic activity, which increases serum calcium levels. Estrogens stimulate osteoblastic (bone-building) activity and inhibit PTH. Thyroxine increases the rate of protein synthesis in all types of tissues, including bone tissues. Growth hormones secreted by the anterior lobe of the pituitary gland are responsible for increasing bone length until puberty.

A client with leukemia who is receiving vincristine reports lower leg numbness. Which statement about vincristine explains this occurrence? A: Vincristine acts on enlarged lymph nodes in the groin. B: Vincristine affects peripheral vascular circulation. C: Vincristine increases the risk for vascular occlusion. D: Peripheral neuropathies can result from vincristine chemotherapy.

D: Peripheral neuropathies can result from vincristine chemotherapy. Muscle weakness, tingling, and numbness are related to medications like vincristine; neuropathies usually are transient if the medication is stopped or reduced. Nodal enlargement produces vascular rather than neural side effects. Most chemotherapeutic regimens do affect the nervous or peripheral vascular system; neuropathies and peripheral vascular adaptations are potential side effects of chemotherapy. Tingling and numbness are characteristic of neuropathy, not vascular occlusion.

Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A: Chest tube insertion B: Aggressive diuretic therapy C: Administration of beta-blockers D: Positive end-expiratory pressure (PEEP)

D: Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

A nurse is caring for a client with a below-the-knee amputation. Which action would the nurse encourage the client to take to prepare the residual limb for a prosthesis? A: Abduct the residual limb when ambulating. B: Dangle the residual limb off the bed frequently. C: Soak the residual limb in warm water twice a day. D: Press the end of the residual limb against a pillow periodically

D: Press the end of the residual limb against a pillow periodically The client usually is instructed to press the end of the residual limb against a pillow to toughen the limb for weight bearing; this process is begun by pushing the residual limb against increasingly harder surfaces. Abduction of the residual limb does not maintain functional alignment and should be avoided; it does not prepare the end of the residual limb for a prosthesis. Dangling the residual limb does not help prepare it for a prosthesis and may impede venous return, which prolongs healing. Soaking the residual limb in warm water twice a day may macerate the residual limb and hinder the use of a prosthesis.

Which action would the nurse take postoperatively to position a client who had an open reduction and insertion of a prosthesis for a fracture of the femoral neck? A: Maintain the affected and unaffected leg in abduction. B: Keep both legs in functional body alignment. C: Intermittently place the client in the prone position. D: Prevent adduction and external rotation of the affected extremity.

D: Prevent adduction and external rotation of the affected extremity. Adduction may cause dislocation of the new prosthesis, and external rotation increases tension on the suture line. Only the operated leg needs to be kept abducted. Keeping both legs in functional body alignment positions the affected leg too close to the midline and increases the danger of hip dislocation. The prone position is not advised because it puts excessive stress on the operative site.

The nurse provides moist heat for a client with cartilage degeneration. Which rational explains the use of this nursing intervention? A: To slow bone loss B: To prevent skin breakdown C: To increase muscle strength D: To increase blood flow to the area

D: To increase blood flow to the area Cartilage degeneration is a physiological change of the musculoskeletal system that can be treated by providing moist heat, which increases blood flow to the area. Weight-bearing exercises are taught to slow bone loss. The client is instructed to prevent pressure on the bony prominences to prevent skin breakdown. The client is taught isometric exercises to increase muscle strength.

The nurse is preparing to apply nitroglycerin ointment. Before applying the ointment, which action will the nurse take? A: Assess the client's pulse rate. B: Prepare the site with an alcohol swab. C: Shave the client's chest in the area for application. D: Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount.

D: Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount. The nurse would use the dose measuring application paper supplied with the ointment and spread in a thin layer to the prescribed amount and place side down on the desired skin. The nurse would assess blood pressure reading, not pulse rate. There is no need to clean the site with alcohol before administration. Shaving is not recommended; a hairless site on the chest, back, abdomen, or anterior thigh should be selected.

Which pain scale would the nurse use when assessing a 4-year-old child? A: CRIES B: FLACC C: Numerical D: Wong-Baker

D: Wong-Baker The Wong-Baker method is a type of faces pain scale best used in children as young as 3 or 4 years. It contains several faces that a child can use to identify his or her pain level. CRIES and FLACC are pain scales typically used with young infants who are unable to verbalize pain. The numerical pain scales are best used in older children, teens, or adults who can accurately assign a number to represent pain level.

Full thickness wound

Extends through dermis to subcutaneous layer, possibly further *Tends to heal slowly, leave scarring, and likely to become chronic

Stage 3 Pressure Injury

Full thickness skin loss that extends into the subcutaneous tissue, but not through fascia to muscle, bone, or connective tissue. Undermining and tunneling may or may not be present. Depth and amount of subcutaneous tissue caries with anatomic location.

Stage 4 Pressure Injury

Full thickness skin loss with exposed or palpable muscle, tendon, or bone. Undermining and tunneling often included. May see the development of sinus tracts. Slough and eschar may often be present on at least part of the wound.

Unstageable Pressure Injury

Full thickness skin loss. The base is completely covered with slough or eschar, obscuring true depth of wound.

Scope of Mobility

Immobility ------> Mobility

Scope of Tissue Integrity

Impaired -----> Intact (normal)

Closed wound

Intact skin (bruising)

Stage 1 Pressure Injury

Intact, non-blistered skim with non-blanchable erythema

Superficial wound

Involves only the epidermis

Partial thickness wound

Involves the dermis and epidermis *Tends to heal quickly, without scarring

Stage 2 Pressure Injury

Partial thickness skin loss involving epidermis and/or dermis. Shallow, superficial pink wound bed. May include intact or ruptured blisters. Bruising is not present.

Hypertension Stage 1

Systolic: 140-159 Diastolic: 90-99

Hypertension Stage 2

Systolic: >160 Diastolic: > 100