Exam 2 Review - Renal, Reproductive SDL

44. Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia? 1. Abnormal diaphoresis. 2. A severe throbbing headache. 3. Sudden loss of motor function. 4. Spastic skeletal muscle movement.

2. A severe throbbing headache.

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? A.Measure her temperature and pulse rate B.Test her urine for the presence of hematuria C.Palpate the right flank for tenderness D.Evaluate the urine for a strong odor

A.Measure her temperature and pulse rate

54. Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."

1. "I will call the surgeon if I experience any difficulty urinating."

*41. The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first? 1. A midstream urine for culture. 2. A sonogram of the kidney. 3. An intravenous pyelogram for renal calculi. 4. A CT scan of the kidneys.

1. A midstream urine for culture. 1. Fever, chills, and costovertebral pain are symptoms of a urinary tract infection (acute pyelonephritis), which requires a urine culture first to confirm the diagnosis. 2. A sonogram of the kidney might be ordered if the client has recurrent UTIs to determine if a physical obstruction is causing the recur-rent infections but not as the first diagnostic procedure. 3. An intravenous pyelogram (IVP) is rarely used to determine pyelonephritis because the results are negative 75% of the time in clients diagnosed with acute pyelonephritis. 4. A CT scan might be ordered if other tests have not been conclusive.

30. The nurse manager in the medical-surgical outpatient clinic is making assignments. Which task is most appropriate to delegate/assign to the UAP/LPN? 1. Ask the LPN to administer the flu vaccine to the client. 2. Tell the UAP to call the pharmacist to refill a prescription. 3. Request the LPN to obtain the height and weight of the client. 4. Instruct the UAP to empty the trashcans in the clients' rooms

1. Ask the LPN to administer the flu vaccine to the client.

31. The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply. 1. Assess for deep vein thrombosis. 2. Administer intravenous anticoagulant. 3. Monitor intake and output strictly. 4. Apply warm compresses to the eyes. 5. Perform passive range-of-motion exercises.

1. Assess for deep vein thrombosis. 3. Monitor intake and output strictly. 5. Perform passive range-of-motion exercises.

*59. The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN.

1. Assess the urine in the continuous irrigation drainage bag. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 1. The nurse should assess the drain postoperatively. 2. The client is hemorrhaging, so the nurse should increase the irrigation fluid to clear the red urine, not decrease the rate. 3. The head of the bed should be lowered and the foot should be elevated to shunt blood to the central circulating system. 4. The surgeon needs to be notified of the change in condition. 5. These laboratory values assess kidney function, not the circulatory system, so this is not an appropriate intervention.

33. The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 4. Plan meals to promote medication effectiveness.

1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 4. Plan meals to promote medication effectiveness.

98. The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.

1. Disuse syndrome. 1. Disuse syndrome is associated with complications of bedrest. Clients with ALS cannot move and reposition themselves, and they frequently have altered nutritional and hydration status.

6. The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center.

1. Inpatient rehabilitation unit.

*16. Which intervention should the nurse include when assessing the client for urinary retention? Select all that apply. 1. Inquire if the client has the sensation of fullness. 2. Percuss the suprapubic region for a dull sound. 3. Scan the bladder with the ultrasound scanner. 4. Palpate from the umbilicus to the suprapubic area. 5. Auscultate the two (2) lower abdominal quadrants.

1. Inquire if the client has the sensation of fullness. 2. Percuss the suprapubic region for a dull sound. 3. Scan the bladder with the ultrasound scanner. 4. Palpate from the umbilicus to the suprapubic area.

28. The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1. Monitor the pulse oximetry reading. 3. Encourage coughing and deep breathing. 5. Administer intravenous corticosteroids. 1. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. 2. A C6 injury would not affect the client's ability to chew and swallow, so pureed food is not necessary. 3. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. 4. Autonomic dysreflexia occurs during the rehabilitation phase, not the acute phase. 5. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

*20. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs every two (2) hours until stable. 2. Measure the client's oral intake and urinary output daily. 3. Administer mouth care when bathing the client. 4. Weigh the client weekly in the same clothing at the same time. 5. Assess skin turgor and mucous membranes every shift.

1. Monitor vital signs every two (2) hours until stable. 5. Assess skin turgor and mucous membranes every shift.

26. In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

1. No reflex activity below the waist. AND if it was a SATA 4. Hypotension and bradycardia.

68. Which intervention should the nurse implement first for the client diagnosed with urinary incontinence? 1. Palpate the bladder after an incontinent episode. 2. Administer oxybutynin, an anticholinergic agent. 3. Ensure the client does not sit or lie in the urine. 4. Instruct the client to go to the bathroom every 2 hours.

1. Palpate the bladder after an incontinent episode.

*33. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. 1. Place the solution on an IV pump at the prescribed rate. 2. Monitor blood glucose every six (6) hours. 3. Weigh the client weekly, first thing in the morning. 4. Change the IV tubing every three (3) days. 5. Monitor intake and output every shift.

1. Place the solution on an IV pump at the prescribed rate. 2. Monitor blood glucose every six (6) hours. 5. Monitor intake and output every shift. 1. TPN is a hypertonic solution with enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too rapid infusion. 2. TPN contains 50% dextrose solution; therefore, the client is monitored to ensure the pancreas is adapting to the high glucose levels. 3. The client is weighed daily, not weekly, to monitor for fluid overload. 4. The IV tubing is changed with every bag because the high glucose level can cause bacterial growth. 5. Intake and output are monitored to observe for fluid balance.

23. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

1. Position the client with the head of the bed elevated at intervals. 1. The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility. 2. Active range-of-motion exercises require that the client participate in the activity. This is not possible because the client is in a coma. 3. The client is at risk for pressure ulcers and should be turned more frequently than every shift, and research now shows that massaging bony prominences can increase the risk for tissue breakdown. 4. The nurse should always talk to the client, even if he or she is in a coma, but this will not address the problem of immobility.

*77. The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care? 1. Provide meticulous skin care and pouching. 2. Apply sterile drainage bags daily. 3. Monitor the pH of the urine weekly. 4. Assess the stoma site every day.

1. Provide meticulous skin care and pouching. 1. Urine is acidic, and the abdominal wall tissue is not designed to tolerate acidic environments. The stoma is pouched so urine will not touch the skin. 2. Urinary diversion drainage bags are changed every four (4) to five (5) days so the skin can remain intact; the bags should be clean but not sterile. 3. The urine will have the normal pH of all urine; it is not necessary to monitor the pH. 4. The stoma should be assessed a minimum of every two (2) hours initially, then every four (4) hours.

60. The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply. 1. Sleep with the head of the bed elevated. 2. Keep a humidifier in the room. 3. Use caution when performing oral care. 4. Stay on a full liquid diet until seen by the HCP. 5. Notify the HCP if developing a cold or fever.

1. Sleep with the head of the bed elevated. 2. Keep a humidifier in the room. 3. Use caution when performing oral care. 5. Notify the HCP if developing a cold or fever.

53. The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make? 1. Social worker. 2. Chaplain. 3. Health-care provider. 4. Occupational therapist.

1. Social worker.

7. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? 1. The 24-year-old client who had a circumcision and is being prepared for discharge. 2. The client scheduled for a cystectomy who is crying and upset about the surgery. 3. The client diagnosed with kidney cancer who is receiving two units of blood. 4. The client who has end-stage renal disease and had an arteriovenous fistula created.

1. The 24-year-old client who had a circumcision and is being prepared for discharge.

12. Which action by the licensed practical nurse (LPN) requires intervention by the critical care charge nurse? 1. The LPN has the trough drawn after hanging the aminoglycoside. 2. The LPN changes out a "sharps" container that is over the fill line. 3. The LPN asks another nurse to observe wastage of a narcotic. 4. The LPN inserts an indwelling urinary catheter into the client.

1. The LPN has the trough drawn after hanging the aminoglycoside.

The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? 1. The client in normal sinus rhythm with a peaked T wave. 2. The client diagnosed with atrial fibrillation with a rate of 100. 3. The client diagnosed with a myocardial infarction who has occasional PVCs. 4. The client with a first-degree atrioventricular block and a rate of 92.

1. The client in normal sinus rhythm with a peaked T wave. 1. A client with a peaked T wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability. 2. Fluctuations in rate are expected in clients diagnosed with atrial fibrillation, and a heart rate of 100 is at the edge of a normal rate. 3. Most people experience an occasional premature ventricular contraction (PVC); this does not warrant the nurse assessing this client first. 4. A first-degree block is not an immediate problem.

35. The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises.

1. The client is able to feed self independently. 1. This medication promotes muscle contraction, which improves muscle strength, which, in turn, allows the client to perform ADLs without assistance. 2. This medication does not affect secretions of the eye. 3. This medication does not help with the digestion of food. 4. This medication does not help with pain; clients with MG do not have muscle pain.

*18. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate the client is complying with client teaching? 1. The client is lying flat in the supine position. 2. The client continues oral fluids restriction while on bedrest. 3. The client uses the bedside commode to urinate. 4. The client refuses to ask for any pain medication.

1. The client is lying flat in the supine position. 1. The client needs to lie flat on the back to apply pressure to prevent bleeding.

14. The charge nurse is making client assignments. Which client should the nurse assign to the graduate nurse who has just finished orientation? 1. The client with a cystectomy who had a creation of an ileal conduit. 2. The client on continuous hemodialysis who is awaiting a kidney transplant. 3. The client with renal trauma secondary to a motor vehicle accident. 4. The client who has had abdominal surgery and whose wound has eviscerated.

1. The client with a cystectomy who had a creation of an ileal conduit.

4. The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first? 1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale. 2. The aminoglycoside antibiotic vancomycin intravenous piggyback (IVPB) to the client with an infected abdominal wound. 3. The proton-pump inhibitor pantoprazole (Protonix) IVPB to the client who is at risk for developing a stress ulcer. 4. The loop-diuretic furosemide (Lasix) intravenous push (IVP) to the client who has undergone surgical debridement of the right lower limb.

1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and is complaining of pain, rating it as a 7 on a 1 to 10 pain scale.

64. The nurse is administering medications on a neurological unit. Which medication should the nurse administer first? 1. The osmotic diuretic to the client with a closed head injury. 2. The morning medications to the client scheduled for physical therapy. 3. The narcotic pain medication to a client with increased intracranial pressure. 4. The anticonvulsant gabapentin (Neurontin) to the client with restless legs syndrome. Correct answer: 1

1. The osmotic diuretic to the client with a closed head injury.

•A practitioner orders a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen? 1. Use a sterile specimen container and maintain the sterility of the container 2. Collect urine from the catheter port 3. Inflate the balloon with 10 mL of sterile water 4. Have the patient void before collecting the specimen

1. Use a sterile specimen container and maintain the sterility of the container

58. The client has received IV solutions for 3 days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation, it is edematous, and a red streak has formed. Which interventions should the nurse implement? Rank in priority order. 1. Start a new IV in the right hand. 2. Discontinue the intravenous line. 3. Complete an incident record. 4. Place a warm washcloth over the site. 5. Document the situation in the client's chart.

2,1,4,5,3

25. The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective? 1. "I can't wait to start back to work next week, I really need the money." 2. "I will take my temperature and if it is above 101 I will call my doctor." 3. "I am glad I won't have to keep track of how much I urinate in the day." 4. "I am happy I will be able eat what I usually eat, I don't like this food."

2. "I will take my temperature and if it is above 101 I will call my doctor."

27. The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2. Administer low-dose subcutaneous anticoagulants. 1. Oxygen is administered initially to maintain a high arterial partial pressure of oxygen (PaO2) because hypoxemia can worsen a neurological deficit to the spinal cord initially, but this client is in the rehabilitation department and thus not in the initial stages of the injury. 2. Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs. 3. The client is unable to move the lower extremities. The nurse should do passive ROM exercises. 4. A client with a spinal injury at C4 or above would be dependent on a ventilator for breathing, but a client with an L1 SCI would not.

101. The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.

2. Administer oxygen via nasal cannula.

20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 5. Administer mild sedatives. 1. The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. 2. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intra-cranial pressure. 3. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. 4. Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided. 5. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.

18. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

2. An intravenous osmotic diuretic. 1. The client in rehabilitation is at risk for the development of deep vein thrombosis; therefore, this is an appropriate medication. 2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit. 3. Clients with head injuries are at risk for post-traumatic seizures; thus an oral anticonvulsant would be administered for seizure prophylaxis. 4. The client is at risk for a stress ulcer; therefore, an oral proton pump inhibitor would be an appropriate medication.

37. The nurse is working at the emergency health clinic in a disaster shelter. Which intervention is priority when initially assessing the client? 1. Find out how long the client will be in the shelter. 2. Determine whether the client has his or her routine medications. 3. Document the client's health history in writing. 4. Assess the client's vital signs, height, and weight.

2. Determine whether the client has his or her routine medications.

49. The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor? 1. Nervousness, metastasis to the lungs, and seizures. 2. Headache, vomiting, and papilledema. 3. Hypotension, tachycardia, and tachypnea. 4. Abrupt loss of motor function, diarrhea, and changes in taste.

2. Headache, vomiting, and papilledema.

*48. The clinic nurse is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication? 1. The antibiotic will treat the bladder spasms that accompany a urinary tract infection. 2. If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth. 3. In three (3) months, the client should be rid of all bacteria in the urinary tract. 4. The HCP is providing the client with enough medication to treat future infections.

2. If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth. 1. Antibiotics may indirectly treat bladder spasms if the spasms are caused by an infec-tion, but this is not the reason for prescribing the antibiotic in this manner. 2. Some clients develop a chronic infection and must receive antibiotic therapy as a routine daily medication to suppress the bacterial growth. The prescription will be refilled after the 90 days and continued. 3. Clients who develop chronic infections may never be free of the bacteria. 4. HCPs do not usually prescribe prn prescriptions for antibiotics.

*64. Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.

2. Nausea; vomiting; pallor; and cool, clammy skin. 1. Dull flank pain and microscopic hematuria are manifestations of a renal stone in the kidney. 2. The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and suprapubic pain when voiding are manifestations of a stone in the bladder. 4. Kidney stones and bladder stones may produce no signs/symptoms, but a ureteral stone always causes pain on the affected side because a ureteral spasm occurs when the stone obstructs the ureter.

21. The nurse in a long-term care facility is administering medications to a group ofclients. Which medication should the nurse administer first? 1. Acetylsalicylic acid (aspirin) to a client diagnosed with cerebrovascular disease. 2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis. 3. Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection. 4. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy. Correct answer: 2

2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis.

*69. Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two (2) hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.

2. Strain all urine and send any sediment to the laboratory.

*31. The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first? 1. Notify the health-care provider immediately. 2. Tap the cheek about two (2) cm anterior to the earlobe. 3. Check the serum calcium and magnesium levels. 4. Prepare to administer calcium gluconate IVP.

2. Tap the cheek about two (2) cm anterior to the earlobe. 1. The HCP may need to be notified, but the nurse should perform assessment first. 2. These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the HCP should be notified immediately because hypocalcemia is a medical emergency. 3. A positive Chvostek's sign can indicate a low calcium or magnesium level, but serum laboratory levels may have been drawn hours previously or may not be available. 4. If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment

The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? 1. The UAP empties the indwelling catheter bag for the client with transurethral resection of the prostate (TURP). 2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall. 3. The UAP provides apple juice to the client with a nephrectomy who has just been advanced to a clear liquid diet. 4. The UAP applies moisture barrier cream to the elderly client with urinary incontinence who has an excoriated perianal area.

2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall.

14. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. 4. The client is able to squeeze the nurse's hand on a verbal request.

2. The client extends the upper and lower extremities in response to painful stimuli. Extension of the upper and lower extremities is assuming a decerebrate posture, which indicates the client's intracranial pressure (ICP) is increasing. This would warrant immediate intervention by the nurse.

26. The nurse is caring for clients in a family practice clinic. Which client should the nurse assess first? 1. The male client with chronic pyelonephritis who has costovertebral tenderness. 2. The female client who is having burning and pain on urination. 3. The female client with urethritis who reports dysuria, urgency, and frequent urination. 4. The male client who has hesitancy, terminal dribbling, and intermittency.

2. The female client who is having burning and pain on urination.

65. The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Keep the client NPO during the time the urine is being collected. 2. Instruct the client to urinate, and include this urine when starting collection. 3. Place client's urine in an appropriate specimen container for 24 hours. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Post signs on the client's door alerting staff to save all of the client's urine output.

3,5

64. The female client with renal calculi is scheduled for a STAT kidney, ureter, bladder (KUB). Which statement by the client warrants intervention by the nurse? 1. "I am allergic to shellfish and iodine." 2. "I just had my lunch tray and ate all of it." 3. "I have not had my period for 3 months." 4. "I am having pain in my lower back."

3. "I have not had my period for 3 months."

57. The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"

3. "Potency can return in six (6) to eight (8) weeks."

80. The client diagnosed with cancer of the bladder states, "I have young children. I am too young to die." Which statement is the nurse's best response? 1. "This cancer is treatable and you should not give up." 2. "Cancer occurs at any age. It is just one of those things." 3. "You are afraid of dying and what will happen to your children." 4. "Have you talked to your children about your dying?"

3. "You are afraid of dying and what will happen to your children."

27. Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.

3. A thymectomy.

2. The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? 1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. 2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

3. An anticholinesterase medication to a client diagnosed with myasthenia gravis.

31. The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3. Assess for bladder distention. 3. This is an acute emergency caused by ex-aggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.

104. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.

3. Assist the client to prepare an advance directive.

*25. The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings? 1. Overhydration. 2. Anemia. 3. Dehydration. 4. Renal failure.

3. Dehydration. 1. Clients who are overhydrated or have fluid volume excess experience dilutional values of sodium (135 to 145 mEq/L) and red blood cells (44% to 52%). The levels are lower than normal, not higher. 2. Anemia is a low red blood cell count for a variety of reasons. 3. Dehydration results in concentrated serum, causing laboratory values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower. 4. In renal failure, the kidneys cannot excrete urine, and this results in too much fluid in the body.

*61. The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two (2) hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).

3. Discuss the importance of limiting vitamin D-enriched foods. 1. This is appropriate for the client who has uric acid stones. 2. The nurse should recommend drinking one (1) to two (2) glasses of water at night to prevent concentration of urine during sleep. 3. Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract. 4. This is a treatment for an existing renal stone, not a discharge teaching intervention for a client who has successfully passed a renal calculus.

12. The client is diagnosed with a brain abscess. Which sign/symptom is the most common? 1. Projectile vomiting. 2. Disoriented behavior. 3. Headaches, worse in the morning. 4. Petit mal seizure activity.

3. Headaches, worse in the morning.

11. The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head. Correct answer: 3

3. Insert an indwelling urinary catheter. Autonomic dysreflexia is a life-threatening condition and can be considered a medical emergency requiring immediate attention. The nurse should not assess but should intervene, and the most common cause is a full bladder.

66. The client diagnosed with renal calculi is 1 hour post-procedure lithotripsy. Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Tell the UAP to check the amount, color, and consistency of the client's urine output. 2. Request the UAP to transcribe the client's healthcare provider's orders. 3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container. 4. Ask the UAP to take the client's post-procedural vital signs.

3. Instruct the UAP to strain the client's urine and place any sediment in a sterile container.

*19. Which intervention should the nurse implement for the client who has had an ileal conduit? 1. Pouch the stoma with a one (1)-inch margin around the stoma. 2. Refer the client to the United Ostomy Association for discharge teaching. 3. Report to the health-care provider any decrease in urinary output. 4. Monitor the stoma for signs and symptoms of infection every shift.

3. Report to the health-care provider any decrease in urinary output. 1. The nurse should maintain the drainage bag with a one-eighth (1/8)-inch border around the stoma. 2. The United Ostomy Association is an excellent referral for information but not for discharge teaching. The nurse retains the responsibility to teach information the client needs to know prior to discharge. 3. The output should be monitored to detect a decreased amount, indicating an obstruction from edema or ureteral stenosis. Any decrease should be reported to the health-care provider. 4. The stoma should be monitored much more frequently than once a shift.

21. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 X 2 gauze under the nose to collect drainage.

3. Test the drainage for presence of glucose.

103. The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with ALS who is refusing to turn every two (2) hours. 2. The client with abdominal pain who is complaining of nausea. 3. The client with pneumonia who has a pulse oximeter reading of 90%. 4. The client who is complaining about not receiving any pain medication.

3. The client with pneumonia who has a pulse oximeter reading of 90%.

*47. The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse? 1. The blood urea nitrogen is 15 mg/dL. 2. The creatinine level is 1.2 mg/dL. 3. The glomerular filtration rate is 40 mL/min. 4. The 24-hour creatinine clearance is 100 mL/min.

3. The glomerular filtration rate is 40 mL/min. 1. Normal blood urea nitrogen levels are 7 to 18 mg/dL or 8 to 20 mg/dL for clients older than age 60 years. 2. Normal creatinine levels are 0.6 to 1.2 mg/dL. 3. Glomerular filtration rate (GFR) is approximately 120 mL/min. If the GFR is decreased to 40 mL/min, the kidneys are functioning at about one-third filtration capacity. 4. Normal creatinine clearance is 85 to 125 mL/min for males and 75 to 115 mL/min for females.

*32. The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement best explains the scientific rationale for the client's Kussmaul's respirations? 1. The kidneys produce excess urine and the lungs try to compensate. 2. The respirations increase the amount of carbon dioxide in the bloodstream. 3. The lungs speed up to release carbon dioxide and increase the pH. 4. The shallow and slow respirations will increase the HCO3 in the serum.

3. The lungs speed up to release carbon dioxide and increase the pH. 1. Kussmaul's respirations are the lung's attempt to maintain the narrow range of pH compatible with human life. The respiratory system reacts rapidly to changes in pH. 2. Respiration is the act of moving oxygen and carbon dioxide. Kussmaul's respirations are rapid and deep and allow the client to exhale carbon dioxide. 3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid). 4. HCO3 (sodium bicarbonate) is an alkaline (base) substance regulated by the kidneys and is part of the metabolic buffer system, not a respiratory system buffer. The excretion and retention of carbon dioxide (CO2) are regu-lated by the lungs and therefore a part of the respiratory buffer system.

57. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavianline. Which precautions should the nurse implement? Select all that apply. 1. Place the client's TPN on a gravity intravenous line. 2. Monitor the client's blood glucose every 24 hours. 3. Weigh the client daily, first thing in the morning. 4. Change the client's IV tubing with every TPN bag administered. 5. Monitor the client's intake and output every shift.

3. Weigh the client daily, first thing in the morning. 4. Change the client's IV tubing with every TPN bag administered. 5. Monitor the client's intake and output every shift.

The client with an implanted port has completed the chemotherapy medications and is ready for discharge. Which intervention should the nurse take to prepare the client for discharge? 1.Teach the client how to manage the port at home. 2.Insert a sterile, non-coring needle into the port. 3.Flush the port with saline followed by heparin. 4.Scrub the port access with povidone-iodine (Betadine).

3.Flush the port with saline followed by heparin. Answer 3. The nurse should make sure all chemo is infused into the client by flushing the port with NS. Instilling heparin into the portal reservoir, and catheter will help to prevent clot formation into the catheter.

37. The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? 1. Start an IV with a 20-gauge catheter. 2. Initiate antibiotic therapy IVPB. 3. Collect a urine specimen for culture. 4. Change the indwelling catheter.

4. Change the indwelling catheter.

3. The nurse is preparing to administer intravenous narcotic medication to the client who has renal calculi and is complaining of pain rated as 8 on 1 to 10 pain scale. The client's vital signs are stable. Which intervention should the nurse implement first? 1. Clamp the IV tubing proximal to the port of medication administration. 2. Administer the narcotic medication slowly over 2 minutes. 3. Check the medication administration record (MAR) against the hospital identification band. 4. Determine if the client's intravenous site is patent.

4. Determine if the client's intravenous site is patent.

21. The elderly female client diagnosed with osteoporosis is prescribed the bisphosphonate medication alendronate (Fosamax). Which intervention is priority when administering this medication? 1. Administer the medication first thing in the morning. 2. Ask the client whether she has a history of peptic ulcer disease. 3. Encourage the client to walk for at least 30 minutes. 4. Have the client remain upright for 30 minutes after administering the medication.

4. Have the client remain upright for 30 minutes after administering the medication. 1. Fosamax {Remember the DRONATE family meds e.g. Alendronate and Risendronate} should be administered in the morning on an empty stomach to increase absorption, but it is not priority over the client's sitting up for 30 minutes. The client should remain upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion. 2. The client with peptic ulcer disease may be more a risk for esophageal erosion, but the HCP should have assessed this prior to prescribing this medication for the client. 3. The client with osteoporosis should be encouraged to walk to increase bone density, but this is not pertinent when administering the medication. 4. Fosamax should be administered on an empty stomach with a full glass of water to promote absorption of the medication. The client should remain upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion.

50. The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position? 1. Widening pulse pressure and bounding pulse. 2. Diplopia and decreased visual acuity. 3. Bradykinesia and scanning speech. 4. Hemiparesis and personality changes.

4. Hemiparesis and personality changes.

33. The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis? 1. A computed tomography (CT). 2. Blood cultures times two (2). 3. Electromyogram (EMG). 4. Lumbar puncture (LP).

4. Lumbar puncture (LP).

*29. The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? 1. Encourage fluids orally. 2. Administer 10% saline solution IVPB. 3. Administer antidiuretic hormone intranasally. 4. Place on seizure precautions.

4. Place on seizure precautions. 4. Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.

61. Which nursing diagnosis is priority for the client who has undergone a transurethral resection of the prostate (TURP)? 1. Potential for sexual dysfunction. 2. Potential for altered urinary elimination. 3. Potential for infection. 4. Potential for hemorrhage.

4. Potential for hemorrhage.

53. Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.

4. Potential for hemorrhage. 1. TURPs can cause a sexual dysfunction, but if there were a sexual dysfunction, it is not priority over a physiological problem such as hemorrhaging. 2. This is not a life-threatening problem. 3. This client has had this problem preoperatively. 4. This is a potentially life-threatening problem.

58. The client diagnosed with a brain tumor has a diminished gag response. Which intervention should the nurse implement? 1. Make the client NPO until seen by the health-care provider. 2. Position the client in low Fowler's position for all meals. 3. Place the client on a mechanically ground diet. 4. Teach the client to direct food and fluid toward the unaffected side.

4. Teach the client to direct food and fluid toward the unaffected side.

36. The home health (HH) nurse enters the home of an 80-year-old female client who had a cerebrovascular accident (CVA), or "brain attack," 2 months ago. The client is complaining of a severe headache. Which intervention should the nurse implement first? 1. Determine what medication the client has taken. 2. Assess the client's pain on a pain scale of 1 to 10. 3. Ask whether the client has any acetaminophen (Tylenol). 4. Tell the client to sit down, and take her blood pressure.

4. Tell the client to sit down, and take her blood pressure.

32. The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after IV fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.

4. The Tensilon test does not show improvement in the client's muscle strength.

55. The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse? 1. The client has purposeful movement with painful stimuli. 2. The client has assumed adduction of the upper extremities. 3. The client is aimlessly thrashing in the bed. 4. The client has become flaccid and does not respond to stimuli.

4. The client has become flaccid and does not respond to stimuli. The most severe neurological impairment result is flaccidity and no response to stimuli. This indicates that the client's condition has worsened.

18. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? 1. The client diagnosed with polycystic kidney disease who has a B/P 170/100. 2. The client diagnosed with bladder cancer who has gross painless hematuria. 3. The client diagnosed with renal calculi who thinks he passed a stone. 4. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated.

4. The client with acute pyelonephritis who has nausea/vomiting and is dehydrated. The client with acute pyelonephritis, an inflammation of the renal parenchyma and collecting system, is not expected to get dehydrated; therefore, this client should be assessed first.

The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.

4. Weakness and paralysis.

*26. The client diagnosed with a fluid and electrolyte disturbance in the emergency department is exhibiting peaked T waves on the STAT electrocardiogram. Which interventions should the nurse implement? List in order of priority. 1. Assess the client for leg and muscle cramps. 2. Check the serum potassium level. 3. Notify the health-care provider. 4. Arrange for a transfer to the telemetry floor. 5. Administer Kayexalate, a cation resin.

Answer: 1, 2, 3, 5, 4

38. The home health (HH) nurse is scheduling visits for the day. Which client should the nurse visit first? 1. The client with an L-4 SCI who is complaining of a severe, pounding headache. 2. The client with amyotrophic lateral sclerosis (ALS) who is depressed and wants to die. 3. The client with Parkinson's disease who is walking with a short, shuffling gait. 4. The client with a C-5 SCI who reports redness and drainage at the Halo vest sites.

Correct answer: 4 1. A severe, pounding headache would be priority for a client with a T-6 or above spinal cord injury (SCI) because it could be autonomic dysreflexia, but not in a client with a lower-level lesion. 2. The client's psychosocial need is not priority over clients with physiological problems. This client should not be visited first. 3. The client with Parkinson's disease is expected to have a short, shuffling gait; therefore, this client does not need to be seen first. 4. The client is reporting an infection at insertion sites into the bone, which can lead to osteomyelitis. This client is exhibiting a potentially life-threatening condition and should be seen first.