Exam 3 Saunders Practice Questions

A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin? 1. Myoflex 2. Aspercreme 3. Topical emollient 4. Acetic acid solution

Answer 3 A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.

The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements? Select all that apply. 1. "I will attempt to stop smoking." 2. "I will be sure to include some exercise such as walking in my daily activities." 3. "I will work at losing some weight so that my weight is at normal range for my age." 4. "I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs." 5. "It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter." 6. "I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure."

Answer 2,3,4,6 Coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Modifiable risk factors include elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. The client is instructed to stop smoking (not cut down), and the nurse should provide the client with resources to do so. The client is also instructed to maintain a normal weight and include physical activity in the daily schedule. The client needs to limit sodium intake and foods high in cholesterol, including red meat and cheese. The client must follow up with regular primary health care provider appointments for physical examinations and monitoring blood pressure.

During electroconvulsive therapy (ECT), the client receives oxygen by mask via positive pressure ventilation. The nurse understands that positive pressure ventilation is necessary for which reason? 1. Seizure activity depresses respirations. 2. Anesthesia is routinely administered during the ECT procedure. 3. Muscle relaxants are given to prevent injury during the seizure. 4. Decreased oxygen to the brain increases confusion and disorientation.

Answer 3 : A short-acting skeletal muscle relaxant is administered during this procedure to prevent injuries during the seizure. The client receives positive pressure ventilation until the muscle relaxant is metabolized, usually within 2 to 3 minutes. The remaining options do not address the specific reason for positive pressure ventilation

A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating? 1. That the client is not adapting well to the disability 2. That the problem is likely to get worse before it gets better 3. That the client is experiencing the usual sequelae of a stroke 4. That the client is experiencing the side effects of prescribed anticoagulants

Answer 3 After a thrombotic stroke, the client often experiences periods of emotional lability, which are characterized by sudden bouts of laughing or crying or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture of the client with this health problem, although it may be difficult for health care personnel and family members to deal with it. The other options are incorrect

A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder? 1. It usually resolves when treated with vasodilator medications. 2. It is similar to stroke, but all symptoms will go away eventually. 3. It is not caused by stroke, and many clients recover in 3 to 5 weeks. 4. The symptoms will completely go away once the tumor is removed.

Answer 3 Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor.

A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication? 1. Tremors and hyperpyrexia 2. Motor restlessness and aphasia 3. Stooped posture and a shuffling gait 4. Muscle weakness and decreased salivation

Answer 3 Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic medications. This condition is characterized by a stooped posture, a shuffling gait, a masklike facial appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is characteristic of the extrapyramidal side effect of neuroleptic malignant syndrome. Motor restlessness, aphasia, muscle weakness, and decreased salivation are not characteristic of pseudoparkinsonism.

Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction? 1. pH 7.25, Paco2 55, HCO3 24 2. pH 7.30, Paco2 38, HCO3 20 3. pH 7.48, Paco2 30, HCO3 23 4. pH 7.49, Paco2 38, HCO3 30

Answer 4 The anticipated ABG finding in the client with a nasogastric tube to continuous suction is metabolic alkalosis resulting from loss of acid. In uncompensated metabolic alkalosis, the pH will be elevated (greater than 7.45), bicarbonate will be elevated (greater than 28 mEq/mL), and the Paco2 will most likely be within normal limits (35 to 45 mm Hg). Therefore, options 1, 2, and 3 are incorrect.

The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)? 1. In left Sims' position 2. In reverse Trendelenburg 3. With the head elevated on a small, flat pillow 4. With the head of the bed elevated at least 30 degrees

Answer 4 The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. The client is log rolled when turned to avoid extreme hip flexion. Therefore, options 1, 2, and 3 are incorrect.

The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate? 1. 45 mm Hg 2. 50 mm Hg 3. 60 mm Hg 4. 80 mm Hg

Answer 4 The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.

The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply. 1. Encourage the client to cough and deep breathe. 2. Add water to the suction chamber as it evaporates. 3. Keep the collection chamber below the client's waist. 4. Clamp the chest tube when the client gets out of bed. 5. Tape the connection between the chest tube and the drainage system.

Answer 1,2,3,5 The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection. To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.

Intravenous 5% albumin is prescribed for a client with burns of the anterior chest and both legs. The nurse contacts the primary health care provider before administering the human albumin if which are noted in the client's record? Select all that apply. 1. Severe anemia 2. Diabetes mellitus 3. Multiple myeloma 4. Renal insufficiency 5. Lymphocytic leukemi

Answer 1,4 Five percent albumin is classified as a blood derivative and is contraindicated in severe anemia, cardiac failure, history of allergic reaction, renal insufficiency, and when no albumin deficiency is present. It is used with caution in clients with low cardiac reserve, pulmonary disease, or hepatic or renal failure

The nurse is caring for an older Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural and spiritual practices and beliefs of the client's homeland. Which questions are most appropriate for the nurse to ask during the admission process? Select all that apply. 1. What do you believe is causing your illness? 2. Why don't you take some asthma medication? 3. Why do you wear that amulet around your neck? 4. Are there any remedies you have used in the past? 5. Who do you usually see for help when you are sick?

Answer 1,4,5 : Assessment includes cultural and spiritual information. It includes questions regarding clients' health beliefs and practices, their health care providers, and their beliefs regarding the origin of illness. Option 2 may have an accusatory undertone. This type of question will not assist the nurse in developing a rapport. A person's reason for wearing an amulet is not relevant to this situation; this question may be perceived as intrusive.

The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis? 1. pH 7.5, Pco2 of 30 2. pH 7.3, Pco2 of 50 3. pH 7.3, HCO3 of 19 4. pH 7.5, HCO3 of 30

Answer 2 : In respiratory acidosis, the pH is decreased and an opposite effect is seen in the Pco2 (pH decreased, Pco2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.

A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present? 1. Eye paralysis and ptosis of the eyelids 2. Chewing difficulties and one-sided facial droop 3. Fixed pupil and an elevated eyelid on one side 4. Twitching of one side of the face and ruddy cheeks

Answer 2 Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.

Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety? 1. "I'm so angry that this happened to me." 2. "I really don't want to live my life like this." 3. "I'm definitely not looking forward to going home." 4. "I don't know if I can make all these major adjustments to my life."

Answer 2 : It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.

4. A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse should plan to have which intervention supplies/equipment readily available at the client's bedside to ensure a safe environment? 1. Code cart 2. Intubation tray 3. Thoracentesis tray 4. Chest tube and drainage system

Answer 2 : Respiratory failure occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client's compensatory mechanisms fail. The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside. A code cart is used for resuscitation. A thoracentesis tray contains the necessary items for performing a thoracentesis. A chest tube drainage system is used to treat a pneumothorax.

The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)? 1. Chest x-ray 2. Sputum culture 3. Complete blood cell count 4. Computed tomography scan of the chest

Answer 2 Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB.

A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder? 1. Exposure to heat 2. Cigarette smoking 3. Diet low in vitamin C 4. Excessive water intake

Answer 2 Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.

The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition? 1. Pain 2. Rash 3. Fever 4. Sneezing

Answer 2 Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.

The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement? 1. "I need to eat foods low in potassium." 2. "I need to check the color of my stools." 3. "I need to check the temperature of my legs twice a day." 4. "I need to take aspirin rather than acetaminophen for a headache."

Answer 2 Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.

The nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin. Which instruction should the nurse include in the plan? 1. Monitor the child's intake and output daily. 2. Provide oral hygiene, especially care of the gums. 3. Administer the medication 1 hour before food intake. 4. Check the child's blood pressure before the administration of the medication.

Answer 2 Focus on the subject, home care instructions regarding phenytoin. Phenytoin is an anticonvulsant medication and causes gum bleeding and hyperplasia; therefore, a soft toothbrush and gum massage should be instituted to diminish this complication and prevent trauma. Intake, output, and blood pressure are not affected by this medication. Directions for administration of this medication include administering it with food to minimize gastrointestinal upset. Review: client instructions for phenytoin

0. The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client? 1. Excessive salivation is a side effect. 2. There will be some pain at the injection site. 3. There should be relief from nausea within 5 minutes. 4. The client may experience increased agitation for about 2 hours.

Answer 2 Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective

A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention should the nurse plan to implement to safely administer the medication? 1. Infuse over 1 hour and allow the client to ambulate. 2. Infuse over 1 hour with the client in a supine position. 3. Administer over 30 minutes with the client in a reclining position. 4. Administer by IV Push over 15 minutes with the client in a supine position.

Answer 2 IV pentamidine is an antifungal medication infused over 1 hour with the client supine to minimize severe hypotension and dysrhythmias. Options 1, 3, and 4 are inaccurate in either the length of time that pentamidine is administered or the client's position.

The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve, which action should the nurse ask the client to perform? 1. Extend the arms. 2. Extend the tongue. 3. Turn the head toward the nurse's arm. 4. Focus the eyes on an object held by the nurse.

Answer 2 Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to extend the tongue. Extending the arms, turning the head toward the nurse's arm, and focusing the eyes on an object do not test the function of the 12th cranial nerve.

The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury? 1. Hypothermia blanket 2. Emergency tracheostomy kit 3. Magnesium sulfate in a ready-to-inject vial 4. Ampule of saturated solution of potassium iodide

Answer 2 Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state.

Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements? 1. A syringe that contains a preservative 2. A heparinized syringe and a bag of ice 3. A heparinized syringe and a preservative 4. A syringe that contains a preservative and a bag of ice

Answer 2 The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.

The nurse is caring for a client who has been diagnosed with bipolar disorder and is in a manic state. The nurse determines that which group of foods would be best for this client? 1. Beef stew, fruit salad, tea 2. Cheeseburger, banana, milk 3. Macaroni and cheese, apple, milk 4. Scrambled eggs, orange juice, coffee

Answer 2 The client in a manic state often has inadequate food and fluid intake as a result of physical agitation. Foods that the client can eat "on the run" are best because the client is too active to sit at meals and use utensils. Additionally, clients in a manic state should not have any products that contain caffeine

A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure? 1. Mole skin-lined heel protectors 2. Regular use of posterior splints 3. Application of pneumatic boots 4. Avoiding dorsal flexion of the foot

Answer 2 The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop

2. The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply. 1. Anosmia 2. Chronic cough 3. Blurry vision 4. Nasal stuffiness 5. Purulent nasal discharge 6. Headache that worsens in the evening

Ans: 1,2,4,5 Chronic sinusitis is characterized by anosmia (loss of smell), a chronic cough resulting from nasal discharge, nasal stuffiness, persistent purulent nasal discharge, and headache that is worse upon arising after sleep. Blurred vision is not associated directly to this condition.

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply. 1. Having suction equipment readily available 2. Keeping all the lights on in the room at night 3. Keeping a padded tongue blade at the bedside 4. Assisting the client to ambulate in the hallway 5. Monitoring the client closely while showering 6. Locking the client's bed in its lowest position

1,4,5,6 Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.

The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client? 1. Reducing anxiety 2. Increasing fluid volume 3. Decreasing cardiac output 4. Promoting a positive body image

AnsweReducing anxiety will help the client during treatment to increase cardiac output and decrease fluid volume. When cardiac output falls as a result of acute pulmonary edema, the sympathetic nervous system is stimulated. Stimulation of the sympathetic nervous system results in the fight-or-flight reaction, which further impairs cardiac function. A disturbed body image is not a common problem among clients with acute pulmonary edema.r 1

The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care? 1. Assist the client from the affected side. 2. Place personal items directly in front of the client. 3. Discourage the client from scanning the environment. 4. Assist the client with grooming the unaffected side first.

Answer 1 : Unilateral neglect is a pattern of a lack of awareness of body parts such as paralyzed arms or legs. Initially the environment is adapted to the deficit by focusing on the client's unaffected side, and the client's personal items are placed on the unaffected side; gradually the client's attention is focused on the affected side. Therefore, the family is taught to assist the client from the affected side, and the client grooms the affected side first. The client needs to scan the entire environment.

A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn? 1. Allen test 2. Turner's sign 3. Babinski reflex 4. Brudzinski's sign

Answer 1 The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.

A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F (38.3° C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take? 1. Notify the primary health care provider. 2. Administer an acetaminophen suppository. 3. Encourage the client to cough and deep breathe. 4. Administer a bronchodilator prescribed on an as-needed basis

Answer 1 The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty with managing saliva or coughing or choking while eating. Because the client has developed a complication that requires medical intervention, the most appropriate action is to contact the primary health care provider. The remaining options are not related to the management of aspiration.

The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first? 1. Apply oxygen. 2. Administer morphine sulfate. 3. Start an intravenous (IV) line. 4. Obtain an electrocardiogram (ECG).

Answer 1 The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.

A client diagnosed with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action should the nurse take when planning a bed assignment? 1. Place the client in a private, well-ventilated room. 2. Plan to transfer the client to the intensive care unit. 3. Reserve the bed furthest away from the door in a double room. 4. Assign the client to share a double room with a noninfectious client.

Answer 1 : According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well ventilated and should have at least 6 to 12 exchanges of fresh air per hour and should be ventilated to the outside if possible. Therefore, option 1 is the only correct choice

Which actions should the nurse implement to prevent ventilatorassociated pneumonia (VAP) in the client who is intubated and on mechanical ventilation? 1. Practice meticulous hand hygiene. 2. Maintain the head of the bed elevation at 10 degrees. 3. Perform suctioning of oral cavity secretions every 4 hours. 4. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.

Answer 1 : Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.

The client is scheduled for a bronchoscopy. Which priority action should the nurse plan to implement? 1. Obtain informed consent. 2. Ask the client about allergies to shellfish. 3. Restrict the diet to clear liquids on the day of the test. 4. Administer preprocedure antibiotics prophylactically.

Answer 1 : Bronchoscopy is a procedure in which the primary health care provider uses a fiber-optic bronchoscope for direct visualization of the larynx, trachea, and bronchi. Because the procedure is invasive, it requires obtaining informed consent from the client. It is unnecessary to inquire about allergies to shellfish before this procedure because contrast dye is not injected. The client is kept NPO for at least 6 hours before the procedure. There is also no need for prophylactic antibiotics.

A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions? 1. "I will report a fever or sore throat to my doctor." 2. "Some joint pain is expected and is nothing to worry about." 3. "I must brush my teeth frequently to avoid damage to my gums." 4. "My urine may turn red in color, but this is nothing to be concerned about."

Answer 1 : Carbamazepine is an anticonvulsant medication and is also used to alleviate the pain associated with trigeminal neuralgia. Agranulocytosis is an adverse effect of carbamazepine, and it places the client at risk for infection. If the client develops a fever or a sore throat, the primary health care provider should be notified. Unusual bruising and bleeding are also adverse effects of the medication, and they need to be reported to the primary health care provider if they occur.

A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer 1 : Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.

The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety? 1. Staying with the client 2. Distracting the client with television 3. Interpreting the arterial blood gas report 4. Encouraging the client to cough and breathe deeply

Answer 1 : Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.

A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period? 1. Place the client on bed rest. 2. Allow the client to ambulate only in the room. 3. Obtain a bedside commode for the client's use. 4. Encourage the client to be up at least twice per day.

Answer 1 : The client is placed on aneurysm precautions, and the client's activity is kept to a minimum to prevent Valsalva's maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, the rest of the options are incorrect actions.

A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client? 1. Noting whether the client has visitors 2. Instructing all staff members to not touch the client 3. Giving the client a roommate with TB who persistently tries to talk 4. Removing the calendar and clock in the room so that the client will not obsess about time

Answer 1 : The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.

The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained? 1. Urine output: 100 mL/hr 2. pH of arterial blood: 7.32 3. Capillary refill: 5 seconds 4. Blood pressure: 90/48 mm Hg

Answer 1 : Urine output at 100 mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the "rule of 100s" in which the systolic blood pressure is maintained at 100 mm Hg, urine output at 100 mL per hour, heart rate at 100 beats per minute, and Pao2 at 100 mm Hg

The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan? 1. Maintenance of intact skin 2. Regaining of bladder and bowel control 3. Performance of activities of daily living independently 4. Independent transfer of self to and from the wheelchair

Answer 1 A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.

The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure? 1. Breath sounds 2. Capillary refill 3. Respiratory rate 4. Oxygen saturation level

Answer 1 After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.

The school nurse provides teaching about the hazards of smoking to a group of high school students. Which comment by a student indicates the need for additional teaching? 1. "Chewing tobacco is much safer than is smoking tobacco." 2. "Smoking during pregnancy increases the risk of stillbirth." 3. "My health is at risk when my family smokes in the house." 4. "Inhaling smoke from other people is a public health issue."

Answer 1 All forms of tobacco use, including chewing tobacco, are health hazards. Smoking during pregnancy, smoking in a household, and secondhand smoke all present health hazards of tobacco use

The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure

Answer 1 Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery. Blood pressure would provide good information about recovery from other types of shock, but not spinal shock.

When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem? 1. "Avoid caffeine in your diet." 2. "Take your temperature every day." 3. "Limit your fluid intake to 1000 mL per 24 hours." 4. "Catheterize yourself every 2 hours as needed to prevent spasm."

Answer 1 Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.

The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission? 1. Offer revaccination to the client. 2. Document the previous immunization on the client record. 3. Instruct the client that this vaccine provides lifelong immunity. 4. Explain to the client that he can be revaccinated only during the fall months

Answer 1 During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.

A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note? 1. Hematocrit 65% (0.65) 2. Albumin 4.0 g/dL (40 g/L) 3. Sodium 140 mEq/L (140 mmol/L) 4. White blood cell (WBC) count 6000 mm3 (6 × 10 9 /L)

Answer 1 Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42- 0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135- 145 mmol/L). The normal WBC count is 5000 to 10,000 mm3 (5-10 × 10 9 /L).

The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? 1. 2 to 3 liters per minute 2. 4 to 5 liters per minute 3. 6 to 8 liters per minute 4. 8 to 10 liters per minute

Answer 1 In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen.

The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN? 1. Asking the client to take sips of water 2. Asking the client to lie down on his right side 3. Asking the client to look up at the ceiling for 30 seconds 4. Instructing the client to void before taking the medication

Answer 1 Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication

A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication? 1. Take the medication with sips of water. 2. Lie on the right side after taking the medication. 3. Hyperextend the neck for 30 seconds before swallowing. 4. Void within at least 10 minutes before taking the medication

Answer 1 Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the next. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.

A mother states to the nurse, "I am afraid that my child might have another febrile seizure." Which therapeutic statement is best for the nurse to make to the mother? 1. "Tell me what frightens you the most about seizures." 2. "Tylenol can prevent another seizure from occurring." 3. "Most children will never experience a second seizure." 4. "Why worry about something that you cannot control?"

Answer 1 Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings. Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear.

The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed? 1. Uses the bell of the stethoscope 2. Asks the client to sit straight up 3. Places the stethoscope directly on the client's skin 4. Encourages the client to breathe slowly and deeply through the mouth

Answer 1 The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing. Priority Nursing Tip: When auscultating breath sounds, the nurse should listen to at least one full respiration in each location (anterior, posterior, and lateral).

The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain? 1. The client's pain rating 2. The nurse's impression of the client's pain 3. Verbal and nonverbal clues from the client 4. Pain relief after appropriate nursing intervention

Answer 1 The client's perception of pain is the hallmark of pain assessment. Usually noted by the client's rating on a scale of 1 to 10, the assessment is documented and followed with appropriate medical and nursing interventions. The nurse's impression and the verbal and nonverbal clues are subjective data. Pain relief after intervention is appropriate but relates to evaluation. Priority Nursing Tip: The nurse must assess the client's pain; pain i

A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site? 1. Petrolatum jelly gauze 2. Sterile 4 × 4 gauze pad 3. Absorbent gauze dressing 4. Gauze impregnated with povidone-iodine

Answer 1 The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. The items in the remaining options would not be selected as the first protective layer

A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family? 1. Inform the friend to directly contact the family and offer assistance to them. 2. Request that the friend come to the client's home during the next home health visit. 3. Report the friend's call to the nurse manager for referral to the client's social worker. 4. Assure the friend that there is no need for assistance since the nurse is visiting daily.

Answer 1 The nurse must uphold the client's rights and does not give any information regarding a client's care needs to anyone who is not directly involved in the client's care. To request that the friend come for teaching is a direct violation of the client's right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend's assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.

The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure? 1. "This is done under general anesthesia." 2. "This procedure is rarely associated with complications." 3. "It may cause congestion when clots get trapped at the filter." 4. "This could possibly eliminate the need for anticoagulant therapy."

Answer 1 The percutaneous approach uses local anesthesia. Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually. There is usually no need for anticoagulant therapy after surgery.

The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives? 1. Flashlight and pulse oximeter 2. Cardiac monitor and suction equipment 3. Padded bed rails and suction equipment 4. Blood pressure cuff and cardiac monitor

Answer 1 The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.

A client experiencing urticaria (hives) and pruritus states to the nurse, "What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy." Which statement made by the nurse is the most therapeutic? 1. "You're troubled that this will extend into your wedding?" 2. "It's probably just due to prewedding jitters. You'll be fine." 3. "The antihistamine will help a great deal, just you wait and see." 4. "Do you think this would really be something that could ruin your wedding?"

Answer 1 The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to "wait and see." This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity

A client admitted to the hospital is suspected of having Guillain-Barré syndrome. Which assessment findings should the nurse identify as manifestations of this disorder? Select all that apply. 1. Dysphagia 2. Paresthesia 3. Facial weakness 4. Difficulty speaking 5. Hyperactive deep tendon reflexes 6. Descending symmetrical muscle weakness

Answer 1,2,3,4 Guillain-Barré syndrome is an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. Motor manifestations include ascending symmetrical muscle weakness that leads to flaccid paralysis without muscle atrophy, decreased or absent deep tendon reflexes, respiratory compromise and respiratory failure, and loss of bladder and bowel control. Sensory manifestations include pain (cramping) and paresthesia. Cranial nerve manifestations include facial weakness, dysphagia, diplopia, and difficulty speaking. Autonomic manifestations include labile blood pressure, dysrhythmias, and tachycardia.

A client is admitted to the hospital in myasthenic crisis. The nurse should ask the client about which precipitating factor for this event? 1. Getting more sleep than usual 2. Not taking prescribed medication 3. A decrease in food intake recently 4. Taking excess prescribed medication

Answer 2 Myasthenic crisis is often caused by undermedication and responds to the administration of cholinergic medications such as neostigmine and pyridostigmine. Increased sleep and change in diet are not precipitating factors. However, overexertion and overeating could possibly trigger myasthenic crisis. Cholinergic crisis is caused by excess medication and responds to withholding of medications

A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply. 1. Assess the client's visual acuity. 2. Observe the client's gait and posture. 3. Evaluate the client's muscle strength. 4. Look for any hazards in the home care environment. 5. Ask a family member to move in with the client until recovery is complete. 6. Request that the client transfer to an assisted living environment for at least 1 month.

Answer 1,2,3,4 To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.

The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply. 1. Pain level 2. Vital signs 3. Hourly urine output 4. Tolerance for sips of clear liquids 5. Ability to cough and deep breathe

Answer 1,2,3,5

. The clinic nurse provides home care instructions to an adult client diagnosed with influenza. Which instructions should the nurse provide to the client? Select all that apply. 1. Practice frequent hand washing. 2. Remain at home until feeling better. 3. Sneeze or cough into the upper sleeve. 4. Return in 1 week for an influenza vaccine. 5. Take acetaminophen for myalgia. 6. Completely isolate self in a room from other family members and use a separate bathroom until feeling better.

Answer 1,2,3,5 : Influenza (commonly known as the flu) refers to an acute viral infection of the respiratory tract. It is a communicable disease spread by droplet infection, and measures are instituted to prevent its spread. The client is instructed to practice frequent hand washing, remain at home, and cover the nose and mouth when sneezing and coughing. Supportive measures to relieve fever and myalgia such as the use of acetaminophen are also encouraged. It is unrealistic to completely isolate oneself in a room from other family members, and there is no useful reason to use a separate bathroom because the infection is spread through droplets. Influenza immunization is administered before the start of the "flu" season, not after developing the infection.

The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply. 1. Assess peripheral circulation. 2. Monitor for abdominal distention. 3. Educate the client that abdominal pain is to be expected. 4. Assess the client for observable ecchymoses on the lower back. 5. Perform deep palpation of the abdomen to assess the size of the aneurysm.

Answer 1,2,4 If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk for rupture.

Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply. 1. Remove any dentures. 2. Remove contact lenses. 3. Provide access to limited food and drink. 4. Ensure that the informed consent is signed. 5. Have the client void before transport to endoscopy.

Answer 1,2,4,5 If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.

The nurse is providing education to the unlicensed assistive personnel (UAP) in preparation for communicating with a hearing-impaired client? Which statements by the UAP indicates that teaching has been effective? Select all that apply. 1. "Speak using a normal tone of voice." 2. "Speak clearly when communicating with the client." 3. "Speak slowly and directly into the client's impaired ear." 4. "Face the client directly when carrying on a conversation." 5. "Be aware of signs that the client does not understand the conversation."

Answer 1,2,4,5 When communicating with a hearing-impaired client, the caregiver should speak in a normal tone to the client and should not shout. One should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is being said, the caregiver should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but one must avoid talking directly into the impaired ear.

A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply. 1. Edema 2. Proteinuria 3. Hypertension 4. Abdominal pain 5. Increased weight 6. Hypoalbuminemia

Answer 1,2,4,5,6 Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.

The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions should the nurse implement to ensure client safety? Select all that apply. 1. Check the client's level of consciousness. 2. Check wheel locks of the operating room table. 3. Complete the client transfer as quickly as possible. 4. Tell the client to move self from the table to the stretcher. 5. Raise side rails after the client is positioned on the stretcher per agency policy.

Answer 1,2,5 As part of the safe transfer of a client after a surgical procedure, the nurse should assess the client's level of consciousness and, if appropriate, let the client know that she or he will be transferred from the operating room table to the stretcher. The nurse checks the wheel locks of the table and the stretcher to prevent any movement during the transfer. In addition, the nurse raises the side rails per agency policy to prevent the client from falling off the stretcher. This is important because the client is likely to be sedated or disoriented and unable to protect herself or himself from falling. Personnel avoid hurried movements and rapid changes in position because hurried movements predispose the client to hypotension; moreover, secure, deliberate movement increases the security of the client. Because the client remains affected by anesthesia, the client should not move herself or himself.

The nurse is obtaining a history from a client who was admitted to the hospital with a thrombotic stroke. What are the most likely signs/symptoms the client experienced before the stroke occurred? Select all that apply. 1. Temporary aphasia 2. Throbbing headaches 3. Transient hemiplegia 4. Paresthesias of the hands and feet 5. Unexplained loss of consciousness

Answer 1,3,4 Cerebral thrombosis does not occur suddenly. During the few hours or days before a thrombotic stroke, the client may experience a transient loss of speech (aphasia), hemiplegia, or paresthesias on one side of the body. Other signs and symptoms of thrombotic stroke vary, but they may include dizziness, cognitive changes, or seizures. Headache is rare, and a loss of consciousness is not likely to occur.

The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply. 1. Maintain the client in a position of comfort. 2. Collect sputum specimens at the hour of sleep. 3. Offer medication to suppress the cough as needed. 4. Administer small, frequent meals with plenty of fluids. 5. Have the client cough and breathe deeply 20 minutes after pain medication is given. 6. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.

Answer 1,4,5 Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breath will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.

The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan? 1. Assisting the client to deal with long-term care placement 2. Including the client's significant others in the teaching session 3. Following up on laboratory and diagnostic tests that were prescribed 4. Including information the primary health care provider has indicated

Answer 2 : Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.

A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication? 1. Decreased nausea 2. Decreased muscle spasms 3. Increased muscle tone and strength 4. Increased range of motion of all extremities

Answer 2 Baclofen should be administered with caution in the client with renal or hepatic dysfunction or a seizure disorder. Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.

A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse should tell the client that this therapy will most likely improve which problem? 1. Double vision 2. Difficulty breathing 3. Urinary incontinence 4. Prickling sensation in the legs

Answer 2 Plasmapheresis is a process that separates the plasma from the blood elements so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually 3 to 5 treatments are required. This therapy is not indicated for the reasons listed in any of the other options

A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care? 1. Implements ROM exercises to the point of pain for the client 2. Considers the use of active, passive, or active-assisted exercises in the home 3. Encourages dependence on the home care nurse to complete the exercise program 4. Develops a schedule involving ROM exercises every 3 hours during daylight hours

Answer 2 The home care nurse must consider all forms of ROM for the client. Even if the client has right hemiplegia, the client can assist with some of his or her own rehabilitative care. In addition, the goal of home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach so that the client becomes self-reliant. Options 1 and 4 are incorrect from a physiological standpoint.

The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight? 1. The client nods that he or she feels comfortable. 2. Two fingers can be slid comfortably under the holder. 3. Four fingers can be slid comfortably under the holder. 4. The tracheostomy does not move more than 0.5 inch when the client coughs.

Answer 2 There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status? 1. Decreased fat intake 2. Decreased fluid intake 3. Sleeping soundly during the night 4. Anxiety about the upcoming pulmonologist visit

Answer 2 The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.

The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family about assuming which position during the postoperative period? 1. Sleep only on the left side. 2. Sleep on the right side or the back. 3. Bend below the waist as often as you are able. 4. Lower the head between the knees three times a day.

Answer 2 : After cataract surgery, the client is informed to sleep on the nonoperative side or his or her back. The client should not sleep on the operative side to prevent the development of edema. The client should also avoid bending below the level of the waist or lowering the head because these actions will increase intraocular pressure

The nurse has given the client with a nephrostomy tube instructions to follow after hospital discharge to prevent complications. The nurse determines that the client understands the instructions if the client verbalizes the need to drink how many glasses of water per day? 1. 1 to 3 2. 6 to 8 3. 10 to 12 4. 14 to 16

Answer 2 The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and provide good mechanical flushing of the kidney and the tube. The nurse encourages the client to take in 2000 mL of fluid per day, which is roughly equivalent to 6 to 8 glasses of water. One to three glasses of water is an inadequate amount. Amounts over 10 glasses of water could distend the renal pelvis.

The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching? 1. "I check my weight every day without fail." 2. "I exercise 3 to 4 hours every day to keep my slim figure." 3. "I've been told that I am 10% below my ideal body weight." 4. "My best friend was in the hospital with this disorder a year ago."

Answer 2 : Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being

The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse should ensure that which specific priority item is at the client's bedside? 1. Cardiac monitor 2. Tracheotomy set 3. Intermittent gastric suction 4. Underwater seal chest drainage system

Answer 2 : Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure.

The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms? 1. Nothing to be concerned about 2. Signs/symptoms of acute glomerulonephritis 3. Signs/symptoms of the normal progression of scarlet fever 4. Symptoms of an allergic reaction to penicillin G potassium

Answer 2 : Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.

A client diagnosed with brain death as a result of a severe head injury had received vigorous treatment to control cerebral edema. Which intervention should the nurse plan to implement as a priority to maintain viability of the kidneys before organ donation? 1. Screen the donor for infection. 2. Administer intravenous (IV) fluids. 3. Maintain ventilation and oxygenation. 4. Administer vasopressors intravenously.

Answer 2 : The kidneys require a minimum perfusion pressure of 80 mm Hg to produce urine and maintain renal function, and because of the aggressive treatment for cerebral edema, the client is likely to have a fluid volume deficiency. Therefore, the nurse restores the intravascular blood volume to maintain the blood pressure and renal perfusion pressure. The nurse screens the donor for infections because diseases such as hepatitis B and human immunodeficiency virus contraindicate organ donation; however, this option is unrelated to viability of the kidneys. Ventilation and oxygenation are important factors in tissue viability; however, the organ must be perfused adequately, first, to deliver any blood. The nurse administers vasopressors with caution to help maintain the donor's blood pressure; however, vasopressors potentially contribute to tissue destruction.

The nurse is admitting a client with an arteriovenous (AV) fistula in the right arm for hemodialysis. Which strategy should the nurse plan to implement to best prevent injury to the AV fistula site? 1. Applying an allergy bracelet to the right arm 2. Placing an alert bracelet per agency procedure on the client's right arm 3. Putting a large note about the access site on the front of the medical record 4. Telling the client to inform all caregivers who enter the room about the presence of the access site.

Answer 2 : There should be no venipunctures or blood pressure measurements in the extremity with a hemodialysis access device. This is commonly communicated to all caregivers by placing an alert bracelet on the arm that needs to be protected. This alert bracelet prompts the primary health care provider to investigate the need for the bracelet. The use of an alert wrist bracelet (rather than a visibly posted note or sign) also maintains client confidentiality. Agency procedure is always followed. An allergy bracelet is placed on the client with an allergy. Placing a note on the front of the medical record does not ensure that everyone caring for the client is aware of the access device. The client should not be responsible for informing the caregivers.

The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful? 1. Place bedside articles on the left side. 2. Approach the client from the right side. 3. Teach the client to scan the environment. 4. Move the commode and chair to the left side.

Answer 2 : Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.

A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention? 1. Identifies that the tube is draining normally 2. Assesses the tube to locate a possible occlusion 3. Auscultates the lungs for appropriate bilateral expansion 4. Assists the client with frequent coughing and deep breathing

Answer 2 After CABG surgery, chest tube drainage should not exceed 100 to 150 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after CABG surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse. Options 1, 3, and 4 are incorrect interventions.

A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching? 1. "I will stop smoking my cigarettes." 2. "I can expect to cough up bright red blood." 3. "I will get help immediately if I start having trouble breathing." 4. "I will use the throat lozenges as directed by my doctor until my sore throat goes away."

Answer 2 After bronchoscopy, expectorated secretions are inspected for hemoptysis, and if the client expectorates bright red blood, the primary health care provider is to be notified. The client needs to avoid smoking. The client should be observed for signs/symptoms of respiratory distress, including dyspnea, changes in respiratory rate, the use of accessory muscles, and changes in or absent lung sounds. A sore throat is common, and lozenges would be helpful to alleviate it.

A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure? 1. Ambulate the client. 2. Clamp the chest tube. 3. Ask the client to cough and deep breathe. 4. Ask the client to remain in a side-lying position

Answer 2 After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.

A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)? 1. An apnea monitor 2. A suction unit and oxygen 3. A blood transfusion warmer 4. An ampule of phytonadione

Answer 2 After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Phytonadione would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration

. The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching? 1. "I wear an eye patch at night." 2. "I am staying on a liquid diet." 3. "I wear dark glasses when I go out." 4. "I have been gently massaging my face."

Answer 2 Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.

A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation? 1. Weight loss 2. Bilateral crackles 3. Distended neck veins 4. Peripheral pitting edema

Answer 2 The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.

The home care nurse is evaluating a client's understanding of the selfmanagement of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching? 1. "I should chew on my good side." 2. "An analgesic will relieve my pain." 3. "I should use warm mouthwash for oral hygiene." 4. "Taking my carbamazepine will help control my pain."

Answer 2 Chronic irritation of cranial nerve V results in trigeminal neuralgia, and it is characterized by intermittent episodes of intense pain of sudden onset on the affected side of the face. The pain is rarely relieved by analgesics. It is recommended that clients chew on the unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine help control the pain of trigeminal neuralgia.

The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged? 1. "I will take all of my antibiotics, even if I do feel 100% better." 2. "You can toss out that incentive spirometer as soon as I leave for home." 3. "I realize that it may be weeks before my usual sense of well-being returns." 4. "It is a good idea for me to take a nap every afternoon for the next couple of weeks."

Answer 2 Deep breathing and coughing exercises and the use of incentive spirometry should be practiced for 6 to 8 weeks after the client diagnosed with pneumonia is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of antibiotics is not taken, the client may suffer a relapse. The period of convalescence with pneumonia is often lengthy, and it may be weeks before the client feels a sense of well-being. Adequate rest is needed to maintain progress toward recovery.

A young adult client diagnosed with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again." Which is the realistic reply for the nurse to make to the client? 1. "It must feel horrible to know you can never have sex again." 2. "It's still possible to have a sexual relationship, but it will be different." 3. "You're young, so you'll adapt to this more easily than if you were older." 4. "Because of body reflexes, sexual functioning will be no different than before."

Answer 2 It is possible to have a sexual relationship after a spinal cord injury, but it is different from what the client will have experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after a spinal cord injury.

The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, "If this is a stroke, it's the kiss of death." What initial response should the nurse make? 1. "Why would you think like that?" 2. "You feel your mother is dying?" 3. "These symptoms are reversible." 4. "A stroke is not the kiss of death."

Answer 2 Option 2 allows the daughter to verbalize her feelings, begin coping, and adapt to what is happening. By restating, the nurse seeks clarification of the daughter's feelings and offers information that potentially helps ease some of the fears and concerns related to the client's condition and prognosis. Option 1 is a disapproving comment that is likely to interfere with communication. Option 3 is potentially misleading and offers false hope. The nurse could reflect back the statement in option 4 to the daughter to promote communication. However, as it stands, option 4 is a barrier to communication that contradicts the daughter's feelings.

A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse should plan to have which intervention supplies/equipment readily available at the client's bedside to ensure a safe environment? 1. Code cart 2. Intubation tray 3. Thoracentesis tray 4. Chest tube and drainage system

Answer 2 Respiratory failure occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client's compensatory mechanisms fail. The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside. A code cart is used for resuscitation. A thoracentesis tray contains the necessary items for performing a thoracentesis. A chest tube drainage system is used to treat a pneumothorax.

A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support? 1. Myasthenic crisis 2. Cholinergic crisis 3. Systemic infection 4. Reaction to plasmapheresis

Answer 2 Signs and symptoms of cholinergic crisis include nausea, vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, pupillary miosis, and hypotension. It is caused by overmedication with cholinergic (anticholinesterase) medications, and it is treated by withholding medications. Myasthenic crisis is an exacerbation of myasthenic symptoms caused by undermedication with anticholinesterase medications. There are no data in the question to support the remaining options.

The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve? 1. Ask the client to raise the forearm above the head. 2. Have the client spread all of the fingers wide and resist pressure. 3. Ask the client to move the thumb toward the palm and then back to the neutral position. 4. Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers.

Answer 2 So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve

The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan? 1. Turn the head slowly when spoken to. 2. Remove throw rugs and clutter in the home. 3. Drive at times when the client does not feel dizzy. 4. Walk to the bedroom and lie down when vertigo is experienced.

Answer 2 The client should maintain the home in a clutter-free state and have thrown rugs removed because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. If vertigo does occur, the client should immediately sit down or lie down (rather than walking to the bedroom) or grasp the nearest piece of furniture

Which instruction should the nurse provide to the client prescribed the medication benztropine mesylate? 1. Sit in the sun for 30 minutes daily. 2. Avoid driving if drowsiness or dizziness occurs. 3. Expect difficulty swallowing while taking this medication. 4. Expect episodes of vomiting and constipation while taking this medication.

Answer 2 The client taking benztropine mesylate, anti-Parkinson's agent and anticholinergic agent, should be instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client's tolerance to heat may be reduced because of the diminished ability to sweat, and the client should be instructed to plan rest periods in cool places during the day. The client should be instructed to contact the primary health care provider immediately if difficulty swallowing or speaking or vomiting occurs. The client should also inform the primary health care provider if central nervous system effects occur. The client is instructed to monitor urinary output and watch for signs of constipation

The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety? 1. Holding the oxygen tank on your lap when traveling 2. Checking the oxygen level of the tank on a regular basis 3. Lighting candles at least a few feet away from the oxygen tank 4. Reporting low oxygen levels in the tank to the primary health care provider (HCP)

Answer 2 The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.

The nurse should question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm? 1. Nicardipine 2. Heparin sodium 3. Docusate sodium 4. Aminocaproic acid

Answer 2 The nurse should question a prescription for heparin sodium, which is an anticoagulant. This medication could place the client at risk for rebleeding. Nicardipine is a calcium channel-blocking agent that is useful in the management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It may be prescribed after ruptured intracranial aneurysm and subarachnoid hemorrhage if surgery is delayed or contraindicated.

A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply. 1. Restrict the client's movements. 2. Turn the supine client to the side. 3. Open the unconscious client's airway. 4. Gently guide the standing client to the floor. 5. Place a padded tongue blade into the client's mouth. 6. Loosen any restrictive clothing that the client is wearing.

Answer 2,3,4,6 Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.

The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply. 1. "All used dishes should be sterilized." 2. "My close contacts should be tested for TB." 3. "Soiled tissues should be disposed of properly." 4. "House isolation is required for at least 8 months." 5. "The mouth should always be covered when coughing."

Answer 2,3,5 Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.

The nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply. 1. Clear sclera 2. Blurred vision 3. Protruding cornea 4. Increased tear production 5. Diminished pupillary adaptation to darkness 6. Increased ability to discriminate among colors

Answer 2,5 Age-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.

A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure? 1. "I understand that this will help relieve the pain." 2. "This unit will eliminate the need for taking so many pain medications." 3. "I am not real happy that I have to stay in the hospital for this treatment." 4. "I am not sure that I am going to like those electrodes attached to my skin."

Answer 3 : It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.

3. The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching? 1. "It is best if I avoid tight clothing and lumpy bedclothes." 2. "I should watch for headache, congestion, and flushed skin." 3. "Signs/symptoms I should watch for include fever and chest pain." 4. "I need to pay close attention to how frequently my bowels move."

Answer 3 Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.

A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for "just a few minutes." Which concepts should the nurse use when explaining why the client must remain in the room? 1. A quiet environment promotes more rapid healing of the aneurysm. 2. Clients with aneurysms need isolation to cope with photosensitivity. 3. Reduced environmental stimuli are needed to prevent aneurysm rupture. 4. The client has disorganization of thoughts and feelings and needs reduced activity.

Answer 3 Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to "cope" with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.

A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety? 1. Encourage deep, rapid breathing during activity. 2. Provide stimulation in the environment to maintain client alertness. 3. Observe vital signs and oxygen saturation periodically during activity. 4. Schedule activities before giving respiratory medications or treatments.

Answer 3 The nurse monitors vital signs, including oxygen saturation, before, during, and after activity to gauge client response. Activities should be planned after giving the client respiratory medications or treatments to increase activity tolerance. The client should use pursed-lip and diaphragmatic breathing to lower oxygen consumption during activity. Finally, the environment should be conducive to rest because the client is easily fatigued.

The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded? 1. Pleuritic chest pain has resolved. 2. The oxygen saturation is greater than 92%. 3. Fluctuations in the water-seal chamber ceased. 4. Suction in the chest drainage system is no longer needed.

Answer 3 When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.

A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms? 1. Inhaling too slowly 2. Exhaling too slowly 3. Not resting adequately between breaths 4. Not forming a tight seal around the mouthpiece

Answer 3 Hyperventilation is the most common cause of respiratory alkalosis, which is characterized by lightheadedness and dizziness. If the client does not breathe normally between incentive spirometer breaths, hyperventilation and fatigue can result.

The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse? 1. "My left eye is tearing a lot." 2. "I have trouble closing my left eyelid." 3. "I don't know how I'll live with this stroke." 4. "I can't feel anything on the left side of my face."

Answer 3 : Bell's palsy is an inflammatory condition that involves the facial nerve (cranial nerve VII). Although it results in facial paralysis, it is not the same as a stroke. Many clients fear that they have had a stroke when the symptoms of Bell's palsy appear, and they commonly believe that the paralysis is permanent. Symptoms resolve, although it may take several weeks. The remaining options are expected assessment findings of the client with Bell's palsy.

A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action? 1. Increases comfort level 2. Decreases anxiety level 3. Calms the persistent cough 4. Takes away nausea and vomiting

Answer 3 : Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.

A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension? 1. Suggesting the client watch television during the procedure as a distraction 2. Talking to the client from the foot of the bed and assisting with the procedure 3. Staying beside the client to give information and encouragement during the procedure 4. Assuring the client that even though there are other clients needing care, the client's needs are most important

Answer 3 : Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.

A client diagnosed with multiple myeloma is receiving intravenous hydration at 100 mL per hour. Which finding indicates to the nurse that the client is experiencing a positive response to the treatment plan? 1. Weight increase of 1 kilogram 2. Respirations of 18 breaths per minute 3. Creatinine of 1.0 mg/dL (88 mcmol/L) 4. White blood cell count of 6000 mm3 (6 × 10 9/L)

Answer 3 : Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal function. Options 2 and 4 are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.

A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, "I'm no good to anyone. I might as well be dead." Which most therapeutic response should the nurse make to the client? 1. "You're not a useless person at all." 2. "I'll ask the psychologist to see you about this." 3. "You appear to be feeling pretty bad about things." 4. "It makes me uncomfortable when you talk this way.

Answer 3 : Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication.

A client with schizophrenia is admitted to the inpatient mental health unit. When asked her name, she responds, "I am Elizabeth, the Queen of England." Which should the nurse recognize this client's statement is indicating? 1. Visual illusion 2. Loose association 3. Grandiose delusion 4. Auditory hallucination

Answer 3 A delusion is an important personal belief that is almost certainly not true and that resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. Loose association is thinking that is characterized by speech in which ideas that are unrelated shift from one subject to another. A hallucination is a false perception

The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent? 1. Avoid using all eye makeup to prevent possible reinfection. 2. Apply hot compresses to decrease pain and lessen irritation. 3. Obtain a new set of contact lenses for use after the infection clears. 4. Isolate for 3 days after beginning antibiotic eye drops to avoid the spread of infection.

Answer 3 Conjunctivitis is inflammation of the conjunctiva. A new set of contact lenses should be obtained. If the client has conjunctivitis, eye makeup should be replaced but can still be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary.

The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention should the nurse perform to provide a safe environment for the client at this time? 1. Place pads on the side rails. 2. Connect the client to a bedside ECG. 3. Remove all food or fluids within the client's reach. 4. Place a water-seal chest drainage set at the bedside.

Answer 3 After this procedure, the client remains NPO until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse should monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.

The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn? 1. Holding a warm compress over the puncture site for 5 minutes 2. Encouraging the client to open and close the hand rapidly for 2 minutes 3. Applying pressure to the puncture site by applying a 2×2 gauze for 5 minutes 4. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

Answer 3 Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis? 1. Examine the client's handwriting movements. 2. Check the stool for clay-colored pigmentation. 3. Ask the client to extend the wrist and the fingers. 4. Check the serum bilirubin and liver enzyme levels.

Answer 3 Asterixis is a rapid, nonrhythmic, abnormal muscle tremor of the wrists and fingers that is commonly associated with hepatic encephalopathy and referred to as "liver flap." Handwriting is a nonspecific and insensitive test of motor function, so the nurse avoids using this to assess for asterixis. Clients with hepatic encephalopathy can experience changes in bowel habits and flatulence, but should not experience a color change. The nurse expects the liver function studies of a client with hepatic encephalopathy to have above-normal results.

The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client? 1. The client's history of falls 2. Assistive devices used by the client 3. The client's postural (orthostatic) vital signs 4. The degree of intention tremors exhibited by the client

Answer 3 Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.

A client recovering from a brain attack (stroke) has become irritable and angry regarding self- limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable? 1. Ignore the behavior, knowing that the client is grieving. 2. Allow longer and more frequent visitation by the spouse. 3. Use supportive statements to correct the client's behavior. 4. Stress that the nurses are experienced and know how the client feels

Answer 3 Clients who have experienced a stroke have many and varied needs. It is also important to support and praise the client for accomplishments. The client may need her or his behavior pointed out so that correction can take place, and the client's behavior should not be ignored. Spouses of a stroke client are often grieving; therefore, more visitations may not be helpful. Additionally, short visits are often encouraged. Stating that the nurse knows how the client feels is inappropriate.

When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic? 1. "Well, I can see you never got to the stop smoking clinic." 2. "Now that your secret is out, may we decide what you are going to do?" 3. "Did you explore the stop smoking program at the senior citizens center?" 4. "I wonder if you realize that by smoking you are slowly killing yourself."

Answer 3 Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client. Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In option 4, the nurse preaches and is judgmental.

Dipyridamole has been prescribed for the client who underwent a valve replacement, and the nurse has provided teaching to the client about the medication. Which statement indicates that the client understands the medication instructions? 1. "This medication will prevent a stroke." 2. "This medication will prevent a heart attack." 3. "This medicine will protect my artificial heart valve." 4. "This medication will help me keep my blood pressure down."

Answer 3 Dipyridamole is an antiplatelet medication. It may be administered in combination with warfarin sodium to protect the client's artificial heart valves. Dipyridamole does not prevent stroke or heart attacks. It is an antiplatelet medication rather than an antihypertensive.

Carbamazepine is prescribed for the management of generalized tonicclonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs? 1. Nausea 2. Dizziness 3. Sore throat 4. Drowsiness

Answer 3 Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse reactions include blood dyscrasias. If the client develops a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the primary health care provider should be notified.

A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client? 1. The client is projecting by insisting that walking is the rehabilitation goal. 2. To speed acceptance, the client needs reinforcement that he will not walk again. 3. Denial can be protective while the client deals with the anxiety created by the new disability. 4. The client needs to move through the grieving process rapidly to benefit from rehabilitation

Answer 3 During the adjustment period that occurs the first few weeks after a spinal cord injury, clients may use denial as a defense mechanism. Denial may decrease anxiety temporarily, and it is a normal part of grieving. After the spinal shock resolves, the prolonged or excessive use of denial may impair rehabilitation. However, rehabilitation programs include psychological counseling to deal with denial and grief.

The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client? 1. Elevate the foot of the bed. 2. Put the bed in reverse Trendelenburg. 3. Position the residual limb flat on the bed. 4. Keep the residual limb slightly elevated with the client lying on the operative side.

Answer 3 Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours only after surgery; however, in the case of an amputation, this practice is controversial. If elevation is allowed, after the first 24 hours, the residual limb is usually placed flat on the bed (as prescribed) to reduce hip contracture. Unless otherwise indicated or prescribed, the residual limb should be placed flat on the bed. Edema is also controlled by residual limb wrapping techniques. Reverse Trendelenburg does not provide direct limb elevation

A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider? 1. Cover the client with warm blankets. 2. Minimize visual and auditory stimuli present. 3. Elevate the client's head to at least 45 degrees. 4. Administer oxygen at 4 L per minute by nasal cannula

Answer 3 Elevating the head of the bed to 45 degrees decreases venous return to the heart from the lower body, thus reducing the volume of blood that has to be pumped by the heart. It also promotes venous drainage from the brain, reducing cerebral symptoms. Oxygen is a medication and is not administered at 4 L without a prescription to do so. Options 1 and 2 are not related to this scenario.

A client with myasthenia gravis is having difficulty with the motor aspects of speech. The client has difficulty forming words, and the voice has a nasal tone. The nurse should plan to use which communication technique when working with this client? 1. Encourage the client to speak quickly. 2. Nod continuously while the client is speaking. 3. Repeat what the client has said to verify the message. 4. Engage the client in lengthy discussions to strengthen the voice.

Answer 3 Focus on the information in the question and the subject, an appropriate communication strategy. The client has speech that is nasal in tone because of cranial nerve involvement in the muscles that govern speech. The nurse should listen attentively and verbally verify what the client has said. Other helpful techniques involve asking questions that require a "yes" or "no" response and developing alternative communication methods (e.g., letter board, picture board, pen and paper, flash cards). Encouraging the client to speak quickly is inappropriate and counterproductive. Continuous nodding may be distracting and is unnecessary. Lengthy discussions will tire the client rather than strengthen the voice. Review: communication techniques for a client with myasthenia gravis.

The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention? 1. Anxiety 2. Depression 3. Suicidal ideation 4. Ineffective coping

Answer 3 Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression

The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops should the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis? 1. Administer the eye drops rapidly. 2. Have a family member instill the eye drops. 3. Lie down on a bed or sofa to instill the eye drops. 4. Keep the eye drops in the refrigerator so that they will thicken.

Answer 3 Older adults diagnosed with Parkinson's disease will experience tremors, making it more difficult to instill eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops to provide control and allow the drops to be administered more easily. If multiple eye drops are needed, there should be a wait time of 3 to 4 minutes between drops. It is unreasonable to expect a family member to be available consistently to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question? 1. "Does being exposed to heat seem to cause the episodes?" 2. "Do the signs and symptoms occur while you are asleep?" 3. "Does drinking coffee or ingesting chocolate seem related to the episodes?" 4. "Have you experienced any injuries that have limited your activity levels lately?"

Answer 3 Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.

A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate? 1. Teaching the client to feel for reddened areas 2. Asking a family member to assess the skin daily 3. Teaching the client to use a mirror for skin assessment 4. Scheduling the client to return to the clinic daily for a skin check

Answer 3 The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.

The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

Answer 3 The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site. Eliminate options 1, 2, and 4 that suggest the site appearance as being reddened.

A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain? 1. Infection or stress 2. Hypoglycemia and fatigue 3. Facial pressure or extreme temperature 4. Excessive watering of the eyes or nasal stuffiness

Answer 3 The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating and drinking, and yawning. Symptoms can also be triggered by thermal stimuli such as a draft of cold air. The items listed in the other options do not trigger the spasm.

The nurse has conducted teaching, with a client who experienced pulmonary embolism, about methods to prevent recurrence after discharge. Which client statement demonstrates understanding of the teaching? 1. "I will limit the intake of fluids." 2. "I will sit down whenever possible." 3. "I am planning to continue to wear supportive hose." 4. "I will cross my legs only at the ankle and not at the knees."

Answer 3 The recurrence of pulmonary embolism can be minimized with the wearing of elastic or supportive hose because these hoses enhance venous return. The client should take in sufficient fluids to prevent hemoconcentration and hypercoagulability. The client also enhances venous return by interspersing periods of sitting with walking, avoiding crossing the legs at the knees or ankles and doing active foot and ankle exercises.

The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively? 1. Hyperoxygenate the client after the procedure only. 2. Apply continuous suction in the airway for up to 20 seconds. 3. Set the wall suction pressure range between 80 and 120 mm Hg. 4. Occlude the Y-port of the catheter while advancing it into the tracheostomy.

Answer 3 The safe wall suction range for an adult is 80 to 120 mm Hg, making option 3 the action that is consistent with safe and effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds. The nurse should advance the catheter into the tracheostomy without occluding the Y-port to minimize mucosal trauma and aspiration of the client's oxygen.

The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met? 1. 3 mcg/mL (11.9 mcmol/L) 2. 8 mcg/mL (31.7 mcmol/L) 3. 15 mcg/mL (59.5 mcmol/L) 4. 24 mcg/mL (95.2 mcmol/L) Level of Cognitive Ability: Eval

Answer 3 The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward

The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced? 1. Partial seizure 2. Absence seizure 3. Tonic-clonic seizure 4. Complex partial seizure

Answer 3 Tonic-clonic seizures are characterized by body rigidity (tonic phase) followed by rhythmic jerky contraction and relaxation of all body muscles, especially those of the extremities (clonic phase). Absence seizures are characterized by a sudden lapse of consciousness for approximately 2 to 10 seconds and a blank facial expression. There are two types of complex partial seizures: complex partial seizures with automatisms and partial seizures evolving into generalized seizures. Complex partial seizures with automatisms include purposeless repetitive activities such as lip smacking, chewing, or patting the body. Partial seizures evolving into a generalized seizure begin locally and then spread through the body.

The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing? 1. Bilateral pain in the area of the sixth cranial nerve 2. Unilateral pain in the area of the sixth cranial nerve 3. Abrupt onset of pain in the area of the fifth cranial nerve 4. Chronic, intermittent pain in the area of the seventh cranial nerve

Answer 3 Trigeminal neuralgia is a chronic syndrome characterized by an abrupt onset of pain. It involves one or more divisions of the trigeminal nerve (cranial nerve V). The remaining options are incorrect

A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching? 1. "I need to avoid heavy lifting for the first 4 to 6 weeks." 2. "I need to take my temperature to detect a possible infection." 3. "I need to remove the chest tube site dressing as soon as I get home." 4. "I need to report any difficulty with breathing to the primary health care provider."

Answer 3 Upon removal of a chest tube, a dressing is usually placed over the chest tube site. This is maintained in place until the primary health care provider says it may be removed. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any respiratory difficulty or increased temperature.

The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving? Select all that apply. 1. Flaccidity 2. Presence of a gag reflex 3. Positive Babinski's reflex 4. Development of hyperreflexia 5. Return of the bulbocavernous reflex 6. Return of reflex emptying of the bladder

Answer 3,4,5,6 Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.

The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem? 1. Meningitis 2. Seizures or head trauma 3. A back injury or spinal cord trauma 4. A respiratory or gastrointestinal (GI) infection

Answer 4 : Guillain-Barré syndrome is a clinical condition of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally it has been triggered by vaccination or surgery. The other options are not associated with an incidence of this syndrome.

A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, Pco2 31 mm Hg, Pao2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acidbase disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer 4 Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the Pco2 is less than 35, whereas respiratory acidosis is present when the Pco2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.

The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect? 1. A sedimentation rate of 15 mm/hour 2. A white blood cell count of 6000 mm3 (6×109/L) 3. A total bilirubin level of 0.3 mg/dL (5.1 mcmol/L) 4. Alanine aminotransferase (ALT) of 80 U/L (80 U/L

Answer 4 Adverse or toxic effects of rifampin include hepatotoxicity, hepatitis, jaundice, blood dyscrasias, Stevens-Johnson syndrome, and antibioticrelated colitis. The nurse monitors for increased liver function, bilirubin, blood urea nitrogen, and uric acid levels because elevations indicate an adverse effect. The normal ALT level is 4 to 36 U/L (4 to 36 U/L). The normal total bilirubin level is 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate is 0 to 30 mm/hour. A normal white blood cell count is 5000 to 10,000 mm3 (5 to 10×10 9 /L).

A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client? 1. Cyanosis and slow respirations 2. Slight bradypnea with shallow breaths 3. Pallor and paradoxical chest movement 4. Severe dyspnea and paradoxical chest movement

Answer 4 The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature

The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status? 1. Vital signs 2. Motor function 3. Sensory function 4. Level of consciousness

Answer 4 The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.

A client remains in diagnosed atrial fibrillation with rapid ventricular response despite prescribed pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. Which action should the nurse plan to take to ensure safety and prevent complications of this procedure? 1. Cardiovert the client at 360 joules. 2. Sedate the client before cardioversion. 3. Ensure that emergency equipment is available. 4. Check that the defibrillator is set on the synchronous mode.

Answer 4 : Cardioversion is similar to defibrillation with two major exceptions: the countershock is synchronized to occur during ventricular depolarization (QRS complex), and less energy is used for the countershock. The rationale for delivering the shock during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often termed the "vulnerable period." If the shock is delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator is set on the "synchronous" mode for a successful cardioversion. Cardioversion usually begins with 50 to 100 joules. Options 2 and 3 will not prevent complications.

A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse should develop a plan of care for the client and include which intervention? 1. Limiting oral and intravenous fluids 2. Measuring the client's pulse once each shift 3. Providing the client with short, frequent walks 4. Eliminating sources of caffeine from meal trays

Answer 4 : In sinus tachycardia, the heart rate is greater than 100 beats per minute. Sinus tachycardia is often caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia and could exacerbate the condition. Measuring the client's pulse during each shift will not decrease the heart rate. Additionally, the pulse should be taken more frequently than once each shift

4. A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client? 1. Belt 2. Waist 3. Wrist 4. Mitten

Answer 4 : Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Belt and waist restraints prevent the client from getting up or falling out of bed or off a stretcher but do nothing to limit hand movement. Wrist restraints cause resistance.

A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking? 1. Bland 2. Full liquids 3. Clear liquids 4. Semisolid foods

Answer 4 : Oral intake after laryngectomy is started with semisolid foods. When the client can manage this type of food, liquids may be introduced. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. Thin liquids are not given until the risk of aspiration is negligible.

The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position? 1. Sit bolt upright in bed with the arms crossed over the chest. 2. Lie on the side with the head of the bed at a 45-degree angle. 3. Sit in a reclining chair tilted slightly back with the feet elevated. 4. Sit on the edge of the bed with the arms leaning on an overbed table.

Answer 4 : Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45 degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.

A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement? 1. A brain tumor presents with few sights/symptoms. 2. It is true that brain tumors are easily recognizable. 3. Brain tumors are never detected until very late in their course. 4. The signs/symptoms of a brain tumor may be easily attributed to another cause.

Answer 4 : Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.

The nurse observes a client looking frightened and reporting, "feeling out of control." Which therapeutic approach by the nurse is most appropriate to maintain a safe environment? 1. Administer a PRN antianxiety medication immediately. 2. Provide isolation for the client in the unit's "time-out" room. 3. Observe the client in an ongoing manner but do not intervene. 4. Encourage the client to talk about her or his feelings in a quiet setting.

Answer 4 : The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.

The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action? 1. Inhale Deeply 2. Breathe Normally 3. Breathe out forcefully 4. Take a deep breath and hold it.

Answer 4 : The client is instructed to take a deep breath and hold it for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space. Therefore, options 1, 2, and 3 are incorrect.

The nurse provides information to a client who is scheduled for the implantation of an implantable cardioverter defibrillator (ICD) regarding care after implantation. The nurse tells the client that there is a need to keep a diary. What information should the nurse provide concerning the primary purpose of the diary? 1. Analyze which activities to avoid. 2. Document events that precipitate a countershock. 3. Provide a count of the number of shocks delivered. 4. Record a variety of data that are useful for the primary health care provider during medical management.

Answer 4 : The client with an ICD maintains a log or diary of a variety of data. This includes recording the date and time of the shock, any activity that took place before the shock, any symptoms experienced, the number of shocks delivered, and how the client felt after the shock. The information is used by the primary health care provider to adjust the medical regimen and especially the medication therapy, which must be maintained after ICD insertion.

A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for what period of time? 1. 1 week 2. 24 hours 3. 5 to 7 days 4. 2 to 3 weeks

Answer 4 Parkinson's disease is a degenerative illness caused by the depletion of dopamine. Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks after starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients must understand this concept to aid in their compliance with medication therapy.

A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement? 1. Fluid restriction 2. Administering diuretics 3. Increased sodium intake 4. Intravenous (IV) replacement of fluid losses

Answer 4 : The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.

The nurse prepares a client for discharge who needs prescribed intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which instruction should the nurse include in client teaching about necessary daily infusion care in the home? 1. Keep the affected arm immobilized. 2. Aspirate 3 mL of blood from the line daily. 3. Maintain a continuous intravenous infusion. 4. Check the insertion site for redness and swelling.

Answer 4 A PICC is designed for long-term intravenous infusions and, usually, is inserted into the median cubital vein with the terminal end of the catheter in the superior vena cava. Although the risk of infection is less with a PICC line than with a central venous catheter, it is possible for phlebitis or infection to develop. Clients must inspect the insertion site and affected arm daily and report any discharge, redness, swelling, or pain to the nurse or provider immediately. A PICC line does not require the affected arm to be immobilized. Although a PICC line can be used to obtain a blood specimen, the risk of occlusion from aspirating blood as part of the related daily care is greater than any potential benefit. The PICC line can be used for intermittent or continuous fluid infusion.

The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern? 1. Lack of knowledge about COPD 2. Difficulty coping related with a situational crisis 3. Negative self-image because of neurological deficit 4. Restricted verbal communication because of a physical barrier

Answer 4 A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options.

The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client? 1. Grief 2. Socialization issues 3. Issues related to sensory perception 4. Trouble with coping with a disease process

Answer 4 A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.

The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position should the nurse assist the client into to maintain safety during the procedure? 1. Right side-lying with the head of the bed flat 2. Prone with the head turned toward the affected side 3. Sims' position with the head of the bed elevated 45 degrees 4. Left side-lying with the head of the bed elevated 45 degrees

Answer 4 A thoracentesis is a procedure in which fluid or air is removed from the pleural space via a transthoracic aspiration. Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.

A client is to have arterial blood gases drawn. While the nurse is performing Allen's test, the client states to the nurse, "What are you doing? No one else has done that!" Which response the nurse makes to the client is most therapeutic? 1. "I assure you that I am doing the correct procedure. I cannot account for what others do." 2. "This step is crucial to safe blood withdrawal. I would not let anyone take my blood until they did this." 3. "Oh? You have questions about this? You should insist that they all do this procedure before drawing up your blood." 4. "This is a routine precautionary step that simply makes certain your circulation is intact before a blood sample is obtained."

Answer 4 Allen's test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response provides information to the client. Option 1 is defensive and nontherapeutic in that it offers false reassurance. Option 2 identifies client advocacy, but it is overly controlling and aggressive, and undermines treatment. Option 3 is aggressive, controlling, and nontherapeutic in its disapproving stance.

A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients? 1. Seek assistance from other staff members. 2. Engage the help of other clients on the unit to accomplish the task. 3. Stop the planning and firmly tell the client that this task is inappropriate. 4. Postpone organizing the dance and supper and engage the client in a writing activity

Answer 4 Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.

2. The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action? 1. Breathes in and then holds the breath for 30 seconds 2. Loosens the abdominal muscles while breathing out 3. Inhales with puckered lips and exhales with the mouth open wide 4. Breathes so that expiration is two to three times as long as inspiration

Answer 4 COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing.

A client is very anxious about receiving chest physiotherapy (CPT) for the first time at home. When planning for the client's care, which concept about CPT should the home care nurse use to reassure the client? 1. CPT will help the client cough more often. 2. There are no risks associated with this procedure. 3. CPT will resolve all of the client's respiratory symptoms. 4. CPT will assist with mobilizing secretions to enhance more effective breathing.

Answer 4 CPT is an intervention to assist with mobilizing and clearing secretions to enhance more effective breathing. CPT will assist the client with coughing if the secretions have been mobilized and the cough stimulus is present. There are risks associated with CPT, including cardiac, gastrointestinal, neurological, and pulmonary effects. It will not resolve all of the client's respiratory symptoms.

A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse should most importantly plan teaching strategies that are designed to do what? 1. Promote membership in support groups. 2. Encourage the client to become a more active person. 3. Identify irritants in the home that interfere with breathing. 4. Improve oxygenation and minimize carbon dioxide retention.

Answer 4 Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.

A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client? 1. Obtain a stat oxygen saturation level. 2. Examine the insertion site for redness. 3. Perform a stat finger-stick glucose level. 4. Turn the client to the left side in Trendelenburg's position.

Answer 4 Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ. Monitoring the oxygen saturation is a reasonable nursing response to the client's condition; however, acting to prevent deterioration in the client's condition is more important than obtaining additional client data. Options 2 and 3 are unrelated to the symptoms identified in the question.

The nurse has taught a client who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu? 1. Cola 2. Coffee 3. Chocolate milk 4. Cranberry juice

Answer 4 Cola, coffee, and chocolate contain xanthine and should be avoided by the client who is taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects that can occur with the use of these types of bronchodilators.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L per minute. The nurse assesses the client's respiratory rate at 22 breaths per minute. When the client reports an increase in the dyspnea, what should the nurse do initially? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collect more information about the client's respiratory status

Answer 4 Completing an assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the primary health care provider, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry.

A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment should the nurse plan to have available at the bedside? 1. Intubation tray 2. Morphine sulfate injection 3. Portable chest x-ray machine 4. Chest tube and drainage system

Answer 4 Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client should be premedicated before the procedure, or a local anesthetic is used. A portable chest x-ray machine would be called for to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.

The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling? 1. The system is intact. 2. A pneumothorax is resolving. 3. The suction to the system is shut off. 4. There is an air leak somewhere in the system.

Answer 4 Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.

The nurse determines that a client is beginning to experience shock and hemorrhage as a result of a partial inversion of the uterus. The client asks in an apprehensive voice, "What is happening to me? I feel so funny, and I know I'm bleeding. Am I dying?" Which typical response is the client experiencing during this medical emergency? 1. Panic as a result of shock 2. Anticipatory grieving related to the fear of dying 3. Depression related to postpartum hormonal changes 4. Fear and anxiety related to unexpected and unknown changes

Answer 4 Feelings of loss of control are common causes of anxiety, and the unknown is the most common cause of fear. Apprehension and feelings of impending doom are also associated with shock, but the information in the question does not suggest panic at this point. Anticipatory grieving occurs when there is knowledge of the impending loss, but it is not associated with a sudden situational crisis such as this one. It is far too early for the onset of postpartum depression.

The nurse assesses the water seal chamber of a close chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement? 1. Unkinking the tubing 2. Assessing for an air leak 3. Documenting that the lung has re-expanded. 4. Documenting that the lungs has not yet re-expanded.

Answer 4 Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate occlusion of the tubing or that the lung has reexpanded. Excessive bubbling in the water seal chamber indicates that an air leak is present.

During an emergency code situation, a primary health care provider about to defibrillate a client diagnosed in ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse immediately implement? 1. Shut off the mechanical ventilator. 2. Shut off the intravenous infusion going into the client's arm. 3. Place the conductive gel pads for defibrillation on the client's chest. 4. Step away from the bed and make sure that all others have done the same.

Answer 4 For the safety of all personnel, when the defibrillator paddles are being discharged, all personnel must stand back and be clear of all contact with the client or the client's bed. It is the primary responsibility of the person defibrillating to communicate the "clear" message loudly enough for all to hear and ensure their compliance. All personnel must immediately comply with this command. Stepping back from the bed prevents the nurse or others from being defibrillated along with the client. A ventilator is not in use during a code; rather, an Ambu (resuscitation) bag is used. Shutting off the intravenous infusion has no useful purpose. The gel pads should have been placed on the client's chest before the defibrillator paddles were applied.

The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next? 1. Administer rescue breathing during the defibrillation. 2. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating. 3. Charge the machine and immediately push the "discharge" buttons on the console. 4. Order any personnel away from the client, charge the machine, and defibrillate through the console.

Answer 4 If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the "discharge" buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as "hands-off" defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt

A clinic nurse providing home care instructions to an adolescent diagnosed with iron deficiency anemia concentrates on the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which liquid? 1. Cola 2. Soda 3. Water 4. Tomato juice

Answer 4 Iron should be administered with vitamin C-rich fluids because vitamin C enhances the absorption of the iron preparation. Tomato juice has a high ascorbic acid (vitamin C) content, whereas cola, soda, and water do not contain vitamin C.

The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition? 1. "I will rest a few minutes before I eat." 2. "I will not eat as much cabbage as I once did." 3. "I will certainly try to drink 3 L of fluid every day." 4. "It's best to eat three large meals a day, so that I will get all my nutrients."

Answer 4 Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client diagnosed with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gasforming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps liquefy pulmonary secretions

A client diagnosed with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. On the basis of this analysis, the nurse should tell the client that it is best to avoid which food to minimize the risk of recurrence? 1. Pasta 2. Lentils 3. Lettuce 4. Spinach

Answer 4 Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion and predispose to stone formation include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, almonds, cashews, rhubarb, and tea

A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question should the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level? 1. "Do you hear ringing in your ears?" 2. "Have you noted that your vision is blurred?" 3. "Have you fallen recently because you are dizzy?" 4. "Have you been experiencing any nausea, vomiting, or diarrhea?"

Answer 4 Normal lithium levels are between 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). One of the most common early signs of lower level lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea. The assessment questions in options 1, 2, and 3 are related to the findings in lithium toxicity at higher levels.

An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first? 1. "Do you have a history of a recent brain abscess?" 2. "Do you have a chronic hearing problem in the left ear?" 3. "Do you successfully obtain pain relief with acetaminophen?" 4. "Do you have a history of a recent upper respiratory infection (URI)?"

Answer 4 Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated

The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred? 1. The prescribed medication therapy has been effective. 2. The client has been taking deep breaths as instructed. 3. The effects of the inflammatory reaction at the site decreased. 4. There is now an accumulation of pleural fluid in the inflamed area.

Answer 4 Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.

A client scheduled for pneumonectomy tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy? 1. "They are generally removed after 36 to 48 hours." 2. "Not every lung surgery requires chest tubes to be used." 3. "They usually remain in place for a full week after surgery." 4. "Your type of surgery rarely requires chest tubes to be inserted after surgery."

Answer 4 Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies. Therefore, options 1, 2, and 3 are incorrect

A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration? 1. Raise the head of the bed. 2. Loosen restrictive clothing. 3. Remove the pillow and raise the padded side rails. 4. Position the client on the side with the head flexed forward.

Answer 4 Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity

A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner? 1. Ask a family member to stay with the client during the procedure. 2. Give the client the call bell, and encourage its use if the client feels worse. 3. Leave the client alone only to gather the required equipment and medications. 4. Stay with the client, and ask another nurse to gather needed equipment and supplies

Answer 4 Pulmonary edema is accompanied by extreme fear and anxiety. Because the client typically experiences a sense of impending doom, the nurse should remain with the client as much as possible. Family members can emotionally support the client, but they are not able to respond to physiological needs and symptoms. In fact, they are typically in psychological distress themselves. Options 2 and 3 do not provide for the psychological needs of the client in distress.

The nurse is creating a teaching plan for the client with Raynaud's disease. Which instruction should the nurse include? 1. Daily cool baths will provide an analgesic effect. 2. A high-protein diet will minimize tissue malnutrition. 3. Vitamin K administration will prevent tendencies toward bleeding. 4. Keeping the hands and feet warm and dry will prevent vasoconstriction.

Answer 4 Raynaud's disease is a vasospasm of the arterioles and arteries of the upper and lower extremities. The use of measures to prevent vasoconstriction is helpful for the management of Raynaud's disease. The hands and feet should be kept dry. Gloves and warm fabrics should be worn in cold weather, and the client should avoid exposure to nicotine and caffeine. The avoidance of situations that trigger stress is also helpful. Taking daily cool baths, maintaining a high-protein diet, and administering vitamin K are not components of the treatment for this disorder.

The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses

Answer 4 Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.

A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured? 1. Widened pulse pressure 2. Unilateral motor weakness 3. Unilateral slowing of pupil response 4. A decline in the level of consciousness

Answer 4 Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.

The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease? 1. A smoker who works in an acute care hospital 2. A person who works with lawn care pesticides 3. A person who does woodworking as a hobby for 8 years 4. A smoker who has cracked asbestos lining on the basement pipes

Answer 4 Smoking greatly enhances the client's risk of developing some form of respiratory disease. Other risk factors include exposure to harmful chemicals, airborne toxins, and dust or fumes. For the options provided, the client who is at the greatest risk has two identified risk factors, one of which is smoking.

The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action should the nurse implement when preparing the client to sit in a chair? 1. Apply knee splints to stabilize the joints during transfer. 2. Teach the client to lock the knees during the pivoting stage of the transfer. 3. Administer a vasodilator in order to improve circulation of the lower limbs. 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes

Answer 4 Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem

A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client-focused action should the nurse encourage in the plan of care? 1. Attend a support group. 2. Cease dwelling on the negative. 3. Reach out for help to face this fear. 4. Share her feelings with her partner.

Answer 4 Talking to the client about sharing her feelings with her husband directly addresses the subject of the question. Encouraging the client to start a support group will not address the client's immediate and individual concerns. Options 2 and 3 are blocks to communication and avoid the client's concern.

The nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client states that which is an appropriate activity? 1. Mowing the lawn 2. Playing a game of 18-hole golf 3. Lifting objects up to 30 pounds 4. Walking as tolerated, including outdoors

Answer 4 The client can walk as tolerated after the repair or resection of an AAA, including walking outdoors. The client should not engage in any activities that involve pushing, pulling, or straining, and the client should not lift objects that weigh more than 15 to 20 pounds for 6 to 12 weeks. Driving is also prohibited for several weeks.

A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client? 1. This problem may decrease the client's life expectancy. 2. The client is likely to be in excruciating pain after surgery. 3. The client will probably have chronic dyspnea after the surgery.

Answer 4 The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. This information supports that the remaining options are not accurate.

A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure should the nurse offer emotional support to the client? 1. This problem may decrease the client's life expectancy. 2. The client is likely to be in excruciating pain after surgery. 3. The client will probably have chronic dyspnea after the surgery. 4. Chest tubes will be in place after surgery, and the healing process is slow.

Answer 4 The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. This information supports that the remaining options are not accurate.

The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Cardiac monitor and intubation tray

Answer 4 The client with Guillain-Barré syndrome is at risk for respiratory failure as a result of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring. Although some of the items in the remaining options may be kept at the bedside (e.g., pulse oximeter, blood pressure cuff, flashlight), they are not necessarily needed for emergency use in this situation.

A client diagnosed with Parkinson's disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client's activities of daily living. Which statement indicates that the teaching has been effective? 1. "We should plan for only a few activities during the day." 2. "We should assist with activities of daily living as much as possible." 3. "We should cluster activities at the end of the day, to help conserve energy." 4. "We should encourage and praise efforts to exercise and perform activities of daily living."

Answer 4 The client with Parkinson's disease has a tendency to become withdrawn and depressed, which can be limited by encouraging the client to be an active participant in his or her own care. The family should plan activities intermittently throughout the day to inhibit daytime sleeping and boredom. The family should also give the client encouragement and praise for his or her perseverance in these efforts and help only when necessary.

The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time? 1. Early in the morning and before lunch 2. Before meals and at the end of the day 3. Early in the morning and late in the day 4. Following exertion and at the end of the day

Answer 4 The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.

The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction? 1. Try to take only small, shallow breaths. 2. Take as much pain medication as possible. 3. Lie on the unaffected side as much as possible. 4. Splint the chest wall during coughing and deep breathing.

Answer 4 The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall.

A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis? 1. High fever and chest pain 2. Increased appetite, dyspnea, and chills 3. Weight gain, insomnia, and night sweats 4. Low-grade fever, fatigue, and productive cough

Answer 4 The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.

The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding? 1. There is a leak in the system. 2. Suction should be added to the system. 3. This is caused by client pneumothorax. 4. Water should be added to the chamber.

Answer 4 The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect

A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, "I'm not sure about this. What if it doesn't work and I'm just as bad off as before?" Which concern for the client should the nurse identify at this time? 1. Anxiety and depression 2. Inability to handle the treatment regimen 3. Lack of knowledge about the surgical procedure 4. Fear about the potential risks and outcomes of surgery

Answer 4 This client has indicated the surgical procedure and its outcome as the object of fear. Anxiety is present when the client cannot identify the source of the uneasy feelings. Presently there are not indications that the client is depressed. A client's inability to handle a treatment regimen would be when the client is not making needed adaptations to deal with daily life. Lack of knowledge would be when there is a lack of appropriate information.

The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action should the nurse take next? 1. Check the client's pupillary responses. 2. Hang the dose of medication immediately. 3. Give a dose of droperidol with the tobramycin. 4. Hold the dose and call the primary health care provider (HCP).

Answer 4 Tobramycin is an antibiotic (aminoglycoside). Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. The nurse should hold the dose and notify the HCP. Ototoxicity is a toxic effect of therapy with aminoglycosides and could result in permanent hearing loss. There is no need to check the pupillary response. Administering the dose would be an unsafe response.

The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication? 1. Pupil response 2. Prothrombin time 3. Skin temperature 4. Intake and output

Answer 4 Urinary retention is a side effect of benztropine mesylate, an anticholinergic medication. The nurse needs to observe for dysuria, distended abdomen, voiding in small amounts, and overflow incontinence. The remaining options do not relate to this medication.

A client experiencing low back pain asks the nurse which type of exercise will strengthen the lower back muscles. Which exercise should the nurse encourage the client to participate in to best strengthen the lower back muscles? 1. Tennis 2. Diving 3. Canoeing 4. Swimming

Answer 4 Walking and swimming are very beneficial in strengthening back muscles for the client with low back pain. The other options involve twisting and pulling of the back muscles, which is not helpful to the client experiencing back pain.

The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety? 1. "My son came to visit me yesterday." 2. "At least I can speak and answer questions." 3. "I have a problem turning my neck to the side." 4. "Look at me, I can no longer be the head of my family."

Answer 4 With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.

The client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years? Fill in the blank and record your answer using one decimal place. Answer: _____ pack-years

Answer 7.5 : The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked three-fourths of a pack per day for 10 years is 0.75 pack × 10 years = 7.5 pack-years.

The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply. 1. Wear support or elastic stockings. 2. Wear well-fitted shoes and walk barefoot when at home. 3. Wear dark-colored stockings or socks and change them daily. 4. Use a heating pad set at low setting on the feet if they feel cold. 5. Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6. Wash the feet and legs with mild soap and water and rinse and dry them well

Answer1,5,6 : Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider, wearing white or colorfast stockings or socks and changing them daily, checking the temperature of the bath water with a thermometer before putting the feet into the water, avoiding the use of heat (hot foot soaks, heating pad, hot water bottle) on the feet because of the risk of burning, avoiding the use of sharp devices to cut nails, and wearing well-fitted shoes and avoiding going barefoot.

A hospitalized client diagnosed with active pulmonary tuberculosis has been receiving multidrug therapy for the past month and is being prepared for discharge. Which finding indicates that respiratory isolation is no longer required and that medication therapy has been effective? 1. Stools are clay colored. 2. Sputum cultures are negative. 3. Tuberculin skin test is negative. 4. Nausea and vomiting have stopped.

The primary laboratory test for pulmonary tuberculosis is a sputum culture. A negative culture indicates the effectiveness of treatment. Clay-colored stools, nausea, and vomiting are side effects of the medication that is used to treat tuberculosis; their presence or absence does not measure the therapeutic effectiveness of the medication. The tuberculin skin test is a screening tool rather than a diagnostic test for tuberculosis. Because the tuberculin skin test indicates exposure to the organism but not active disease, the test results will remain positive

After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage? 1. Lethargy 2. Headache 3. Erythematous rash 4. Cardiac dysrhythmias

Answer 4 : Stage II of Lyme disease develops within 1 to 3 months in most untreated individuals. The most serious problems in this stage include cardiac dysrhythmias, dyspnea, dizziness, and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy), muscle pain and stiffness, and a rash appear in stage I.

The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw? 1. That no action is required. 2. The head of the bed needs to be lowered. 3. The infant needs to be placed on NPO status. 4. The primary health care provider should be notified immediately

Answer 1 The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. Noting a bulging fontanel when the infant cries is a normal finding that requires no action. It is not necessary to notify the primary health care provider. Options 2 and 3 are inappropriate actions.

A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level? 1. 5% 2. 10% 3. 15% 4. 25%

Answer 1 : Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%. Normal carboxyhemoglobin (HbCO) levels are 0% to 3% for nonsmokers and 3% to 8% for smokers. Levels of 10% to 20% cause headaches, nausea, vomiting, and dyspnea. Levels of 30% to 40% cause severe headaches, syncope, and tachydysrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Options 2, 3, and 4 are elevated levels.

A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report? 1. Amenorrhea 2. Menorrhagia 3. Metrorrhagia 4. Dysmenorrhea

Answer 1 Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease

7. The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client to manage emotional stressors by using mental imaging. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone orally per the primary health care provider's prescription

Answer 1 Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms

The client states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding? 1. Orthopnea 2. Dyspnea at rest 3. Dyspnea on exertion 4. Paroxysmal nocturnal dyspnea

Answer 1 Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a "three-point" position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.

A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68 and a Paco2 of 51. Two hours ago the Pao2 was 82 and the Paco2 was 44. Based on these changes, which item should the nurse assure easy access to in order to help ensure client safety? 1. Intubation tray 2. Injectable lidocaine 3. Chest tube insertion set 4. Portable chest x-ray machine

Answer 1 Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The laboratory results indicate worsening respiratory acidosis. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end-expiratory pressure (PEEP); therefore, an intubation tray is necessary. None of the other options have a direct purpose with the client's current respiratory status.

A client experiencing difficulty breathing and increased pulmonary congestion was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment value indicates that the therapy has been effective? 1. The lungs are now clear upon auscultation. 2. The urine output has increased by 400 mL. 3. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg. 4. The serum potassium has decreased from 4.7 mEq to 4.1 mEq (4.7 mmol/L to 4.1 mmol/L).

Answer 1 Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.

A client at risk for respiratory failure is receiving oxygen via nasal cannula at 6 L per minute. Arterial blood gas (ABG) results indicate pH 7.29, Pco2 49 mm Hg, Po2 58 mm Hg, and HCO3 18 mEq/L. What intervention should the nurse anticipate that the primary health care provider will prescribe for respiratory support for this client? 1. Intubating for mechanical ventilation 2. Keeping the oxygen at 6 L per minute via nasal cannula 3. Lowering the oxygen to 4 L per minute via nasal cannula 4. Adding a partial rebreather mask to the current prescription

Answer 1 If respiratory failure occurs and supplemental oxygen cannot maintain acceptable Pao2 and Paco2 levels, endotracheal intubation and mechanical ventilation are necessary. The client is exhibiting respiratory acidosis, metabolic acidosis, and hypoxemia. Lowering or keeping the oxygen at the same liter flow will not improve the client's condition. A partial rebreather mask will raise CO2 levels even further.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3− is 30, which additional value is most likely to be noted in this client? 1. pH 7.52 2. pH 7.36 3. pH 7.25 4. pH 7.20

Answer 1 Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.

The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present? 1. A dull red tympanic membrane 2. A mobile tympanic membrane 3. A transparent tympanic membrane 4. A pearly colored tympanic membrane

Answer 1 Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.

After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the case of this client's pleural effusion? 1. Trauma 2. Infection 3. Liver failure 4. Heart failure

Answer 1 Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.

The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item should the nurse eliminate from this client's diet? 1. Spinach 2. Custard 3. Scrambled eggs 4. Mashed potatoes

Answer 1 Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are foods commonly excluded from the diet of a client with a poor swallowing reflex. In general, flavorful, warm, or well-chilled foods with texture stimulate the swallowing reflex. Soft and semisoft foods such as custards or puddings, egg dishes, and potatoes are usually effective.

8. The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) should assess the infant for which manifestations? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Retractions 4. Nasal flaring 5. Acrocyanosis 6. Grunting respirations

Answer 1, 2,3,4,6 The newborn infant with RDS may present with clinical manifestation of cyanosis, tachypnea or apnea, chest wall retractions, audible grunts, or nasal flaring. Acrocyanosis, the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life.

A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply. 1. Thyroxine (T4 ) 2. Prolactin (PRL) 3. Triiodothyronine (T3 ) 4. Growth hormone (GH) 5. Luteinizing hormone (LH) 6. Adrenocorticotropic hormone (ACTH)

Answer 1, 3 Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4 ). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.

Which questions should the nurse ask when assessing a client for possible manifestations of Ménière's disease? Select all that apply. 1. "Do you experience ringing in your ears?" 2. "Are you prone to vertigo that can last for days?" 3. "Can you hear better out of one ear than the other?" 4. "Is there a history of Ménière's disease in your family?" 5. "Have you ever experienced a head injury in the area of your ears?"

Answer 1,2,3 Ménière's disease is characterized by dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. Manifestations include tinnitus, vertigo that can last for days, and one-sided sensorineural hearing loss. Although the exact cause of the disease is unknown, there does not seem to be a connection with either genetics or head trauma.

The nurse monitoring a postoperative client should recognize which behaviors as indicators that the client is in pain? Select all that apply. 1. Gasping 2. Lip biting 3. Muscle tension 4. Pacing activities 5. Staring out the window 6. Asking for the television to be turned off

Answer 1,2,3,4 The nurse should assess verbalization, vocal response, facial and body movements, and social interaction as indicators of pain. Behavioral indicators of pain include gasping, lip biting (facial expressions), muscle tension, pacing activities, moaning, crying, grunting (vocalizations), grimacing, clenching teeth, wrinkling the forehead, tightly closing or widely opening the eyes or mouth, restlessness, immobilization, increased hand and finger movements, rhythmic or rubbing motions, protective movements of body parts (body movement), avoidance of conversation, focusing only on activities for pain relief, avoiding social contacts and interactions, and reduced attention span. Options 5 and 6 are not to be assumed as pain-related behaviors because there can be a variety of reasons for such actions.

The nurse is caring for a client prescribed digoxin. Which manifestations correlate with a digoxin level of 2.3 ng/dL (2.93 nmol/L)? Select all that apply. 1. Nausea 2. Drowsiness 3. Photophobia 4. Increased appetite 5. Increased energy level 6. Seeing halos around bright objects

Answer 1,2,3,6 : Digoxin is a cardiac glycoside used to manage and treat heart failure, control ventricular rate in clients with atrial fibrillation, and treat and prevent recurrent paroxysmal atrial tachycardia. The therapeutic range is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). Signs of toxicity include gastrointestinal disturbances, including anorexia, nausea, and vomiting; neurological abnormalities such as fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares; facial pain; personality changes; and ocular disturbances such as photophobia, halos around bright lights, and yellow or green color perception.

Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator? Select all that apply. 1. Audible crackles 2. Client notably restless 3. Visible mucus bubbling in the ET tube 4. Apical pulse rate of 72 beats per minute 5. Low peak inspiratory pressure on the ventilator 6. High alarm pressures identified by the ventilator

Answer 1,2,3,6 Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high-pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.

A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply. 1. Cardiac murmur 2. Cardiac enlargement 3. Cool pale skin over the joints 4. White painful skin lesions on the trunk 5. Small nontender lumps on bony prominences 6. Purposeless jerky movements of the extremities and face

Answer 1,2,5,6 Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.

The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply. 1. Dyspnea 2. Cyanosis 3. Tachypnea 4. Kussmaul's respiration 5. Irregular respiratory pattern 6. Adventitious bubbling lung sounds

Answer 1,2,5,6 Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or CheyneStokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing. In an adult, it would indicate a respiratory rate of over 20 breaths per minute

A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescription for this client? Select all that apply. 1. Supplemental oxygen 2. High Fowler's position 3. Semi-Fowler's position 4. Morphine sulfate intravenously 5. Two tablets of acetaminophen with codeine 6. Meperidine hydrochloride intravenously

Answer 1,3,4 Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation

The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse should include which interventions in the plan? Select all that apply. 1. Changing the client's position often 2. Clamping the chest tube intermittently 3. Maintaining the collection chamber below the client's waist 4. Adding water to the suction control chamber as it evaporates 5. Taping the connection between the chest tube and the drainage system

Answer 1,3,4,5 Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.

Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply. 1. Obtaining a chest x-ray 2. Obtaining a throat culture 3. Monitoring pulse oximetry 4. Maintaining a patent airway 5. Providing humidified oxygen 6. Administering antipyretics and antibiotics

Answer 1,3,4,5,6 Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.

A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply. 1. Fever 2. Leukopenia 3. Bradycardia 4. Pericardial friction rub 5. Decreased erythrocyte sedimentation rate 6. Precordial chest pain that is intensifies by the supine position

Answer 1,4,6 In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.

When a client with a chest injury is suspected of experiencing a pleural effusion, the nurse should assess for which typical manifestations of this respiratory problem? Select all that apply. 1. Dry cough 2. Moist cough 3. Dyspnea at rest 4. Productive cough 5. Dyspnea on exertion 6. Nonproductive cough

Answer 1,5,6 A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.

A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure? 1. Ambulate the client. 2. Clamp the chest tube. 3. Ask the client to cough and deep breathe. 4. Ask the client to remain in a side-lying position.

Answer 2 After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.

The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate? 1. Begin administering supplemental oxygen. 2. Document the findings according to facility policies. 3. Notify the child's primary health care provider immediately. 4. Reassess the respiratory rate, rhythm, and depth in 15 minutes.

Answer 2 The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings

A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription should the nurse anticipate will be prescribed for the client before the procedure? 1. An opioid 2. A sedative 3. A corticosteroid 4. An antihistamine

Answer 2 : An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine. Open MRI systems are available in some diagnostic facilities and this method of testing can be used for clients with claustrophobia

The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed? 1. Dextran 2. 0.9% normal saline 3. 5% dextrose in water 4. 5% dextrose in 0.9% normal saline

Answer 2 : Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.

A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation? 1. Radiation is the treatment of choice. 2. The most significant symptoms are headache and vomiting. 3. Head shaving is not required before removal of the brain tumor. 4. Surgery is not normally performed because of the increased risk of functional deficits

Answer 2 :The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children

The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client's acid-base balance? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus

Answer 2 A client with late-stage salicylate poisoning is at risk for metabolic acidosis because acetylsalicylic acid increases the client's hydrogen ion (H+ ) concentration, decreases the pH, and creates a bicarbonate deficit. Hyperkalemia develops as the body attempts to compensate for the influx of H+ by moving H+ into the cell and potassium out of the cell; thus, potassium accumulates in the extracellular space. Clinical manifestations of metabolic acidosis include the clinical indicators of hyperkalemia, including hyperpnea, central nervous system depression, twitching, and seizures. Options 1, 3, and 4 are not primary concerns.

A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness and the primary health care provider prescribes a edrophonium test, also known as a Tensilon Test. A test dose is administered and the client become weaker/ How should the nurse interpret these results? 1. Myasthenic crisis is present. 2. Cholinergic crisis is present 3. This result is a normal finding. 4. This result is a positive finding.

Answer 2 An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.

During history taking of a client admitted with newly diagnosed Hodgkin's disease which symptom should the nurse expect the client to report? 1. weight gain 2. Night sweats 3. Severe lymph node pain 4. Headache with minor visual changes

Answer 2 Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.

A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client? 1. Hot cocoa with honey and toast 2. Vanilla pudding and lukewarm milk 3. Hot herbal tea with graham crackers 4. Iced coffee and peanut butter and crackers

Answer 2 Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain

Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse should explain it is from which source? 1. A cadaver 2. Another animal species 3. The burned client themselves 4. A man-made synthetic source

Answer 2 Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pig skin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client. Synthetic dressings are also available for covering burn wounds

The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis? 1. An evening sweat potassium concentration greater than 60 mEq/L 2. A sweat chloride concentration that is consistently greater 60 mEq/L 3. An early morning sweat chloride concentration of less than 40 mEq/L 4. A sweat potassium concentration that is consistently less than 40 mEq/L

Answer 2 Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to the sweat test

The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury? 1. Abnormal involuntary flexion of the extremities 2. Abnormal involuntary extension of the extremities 3. Upper extremity extension with lower extremity flexion 4. Upper extremity flexion with lower extremity extension

Answer 2 Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.

A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement? 1. Maintaining an intravenous access 2. Ensuring that oxygen is being delivered 3. Administering sedation to prevent claustrophobia. 4. Providing emotional support to the client's family.

Answer 2 Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.

The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client's beliefs? 1. Is accepting of body size 2. Views purging as an accepted behavior 3. Overeats for the enjoyment of eating food 4. Overeats in response to losing control of diet

Answer 2 Individuals with bulimia nervosa develop cycles of binge eating, followed by purging. They seldom attempt to diet and have no sense of loss of control. Options 1, 3, and 4 are true of the obese person who may binge eat (not purge).

A client has been prescribed procainamide. The nurse implements which intervention before administering the medication to minimize the client's risk for injury? 1. Obtaining a chest x-ray 2. Assessing blood pressure and pulse 3. Obtaining a complete blood cell count and liver function studies 4. Scheduling a drug level to be drawn 1 hour after the dose is administered

Answer 2 Procainamide is an antidysrhythmic medication. Before the medication is administered, the client's blood pressure and pulse are checked. This medication can cause toxic effects, and serum blood levels would be checked before administering the medication (therapeutic serum level is 4 to 10 mcg/mL [17.00 to 42.50 mcmol/L]). A chest x-ray and obtaining a complete blood cell count and liver function studies are unnecessary.

A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication? 1. Repositions side to side every 2 hours 2. Elevates the head of the bed 60 degrees 3. Auscultates the lung fields every 4 hours 4. Encourages deep breathing exercises every 2 hours

Answer 2 The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. Although assessment is the first step of the nursing process, the stem of the question identifies the assessment findings ascites and difficulty breathing, so the best answer is to intervene based on the assessment data, by elevating the head of the bed to make the client's breathing easier. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.

The nurse reviews the client's most recent blood gas results that include a pH of 7.43, Pco2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present? 1. Compensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated respiratory acidosis 4. Uncompensated metabolic alkalosis

Answer 2 The normal pH is 7.35 to 7.45, the normal Pco2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the Pco2 move in opposite directions; that is, the pH rises and the Pco2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The Pco2 is low, indicating a respiratory condition (opposite direction of the pH).

A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway? 1. Insert oropharyngeal airway. 2. Tilt the head and lift the chin. 3. Place in the recovery position. 4. Stabilize the skull and push up the jaw

Answer 4 The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.

The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment? 1. "We need to be very careful since oxygen is extremely flammable." 2. "It's important that the child isn't allergic to the antibiotic that is prescribed." 3. "It's difficult to watch the needle be inserted when intravenous fluids are needed." 4. "Chest physiotherapy will loosen the congestion, so coughing will clear the lungs."

Answer 2 The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.

When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply. 1. Bradycardia 2. Increased diaphoresis 3. Decreased lacrimation 4. Bowel and bladder incontinence 5. Absent cough and swallow reflex 6. Sudden marked rise in blood pressure

Answer 2,4,5,6 Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria

The nurse managing a client's post-supratentorial craniotomy care should assure that the client is maintained in which position? 1. Prone 2. Supine 3. Semi-Fowler's 4. Dorsal recumbent

Answer 3 After supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins and modulate intracranial pressure (ICP). Options 1, 2, and 4 are incorrect positions after this surgery because they are likely to increase ICP.

The nurse is monitoring a client who was recently prescribed total parenteral nutrition (TPN). Which action should the nurse take when obtaining a finger stick glucose reading of 425 mg/d: (24.28 mmol?L)? 1. Stop the TPN 2. Administer Insulin 3. Notify the primary health care provider 4. Decrease the flow rate of TPN.

Answer 3 Hyperglycemia is a complication of TPN, and the nurse should report abnormalities to the primary health care provider. Options 1, 2, and 4 are not done without a primary health care provider's prescription.

An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure? 1. Try to swallow. 2. Hold your breath. 3. Breathe normally. 4. Roll the tongue to the back of the mouth.

Answer 3 Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.

The home care nurse assesses a client diagnosed with COPD who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2L per minute, and has a respiratory rate of 22 breathes per minute. Which action should the nurse take? 1. Determine the need to increase the oxygen. 2. Reassure the client that there is no need to worry. 3. Conduct further assessment of the client's respiratory status. 4. Call the emergency services to take the client to the emergency department.

Answer 3 With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is "no need to worry" is inappropriate. Calling emergency services is a premature action.

An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is normal when which element is negative? 1. Protein 2. Glucose 3. Red blood cells 4. White blood cells

Answer 3 The adult with a normal CSF has no red blood cells in the CSF. Protein (15-45 mg/dL [0.15-0.45 g/L]) and glucose (50-75 mg/dL [2.8- 4.2 mmol/L]) are normally present in CSF. The client may have small levels of white blood cells (0-5 cells/mcL [0-5×10 6 /L])

The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform? 1. Obtain isopropyl alcohol to add to the bath water. 2. Allow 5 minutes for the child to soak in the bath water. 3. Have cool water available to add to the warm bath water. 4. Warm the water to the same body temperature as the child's.

Answer 3 : Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.

1. The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? 1. Equal bilateral chest expansion 2. Respiratory rate of 22 breaths per minute 3. Diminished breath sounds on the affected side 4. Few scattered wheezes, unchanged from baseline

Answer 3 : After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds? 1. Absent 2. Vesicular 3. Bronchial 4. Bronchovesicular

Answer 3 : Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse should look for which sign characteristic of this condition? 1. Turner's sign 2. Chvostek's sign 3. Nikolsky's sign 4. Trousseau's sign

Answer 3 A hallmark sign of pemphigus vulgaris is Nikolsky's sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foulsmelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Turner's sign refers to a grayish discoloration of the flanks and is seen in clients with acute pancreatitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm with a blood pressure cuff inflated above the systolic pressure and causing ischemia to the nerves distally.

The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line. Which is a priority intervention of assure the client's safety? 1. Assessing the client's pain level 2. Assessing the client's temperature. 3. Preparing the client for a chest x-ray 4. Monitoring the client's blood pressure (BP)

Answer 3 A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and verify catheter tip placement before initiating IV therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Pain management is important but is not the priority at this point. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for? 1. Cyanosis with accompanying pallor. 2. Diffuse crackles and rhonchi on chest auscultation. 3. Increase in respiratory rate from 18 to 30 breathes per minute. 4. Haziness or "white-out" appearance of lungs on chest radiograph.

Answer 3 ARDS usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or "white-out" appearance in the later stages.

An emergency department nurse prepares to plan care for a child diagnosed with acetaminophen overdose. The nurse reviews the primary health care provider's prescriptions and prepares to administer which medication? 1. Succimer 2. Vitamin K 3. Acetylcysteine 4. Protamine sulfate

Answer 3 Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally or via nasogastric tube in a diluted form with water, juice, or soda. It can also be administered intravenously (undiluted). Protamine sulfate is the antidote for heparin. Succimer is used in the treatment of lead poisoning. Vitamin K is the antidote for warfari

A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder? 1. Increased leukocyte count 2. Decreased hemoglobin count 3. Increased antistreptolysin-O (ASO titer) 4. Decreased erythrocyte sedimentation rate

Answer 3 Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis

The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information should the nurse share with the client about the therapy? 1. After the initial dose, subsequent treatments must continue lifelong. 2. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose. 3. It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease. 4. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.

Answer 3 Graves' disease is also known as toxic diffuse goiter and is characterized by a hyperthyroid state resulting from hypersecretion of thyroid hormones. After treatment with radioactive iodine therapy, a decrease in the thyroid hormone level should be noted, which helps alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. Occasionally, a client may require a second or third dose, but treatments are not lifelong. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse must reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates.

A client is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding? 1. Loud wheezing 2. Wheezing on expiration 3. Noticeably diminished breath sounds 4. Increased displays of emotional apprehension;

Answer 3 Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced

A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial? 1. Obtain baseline arterial blood gases. 2. Obtain baseline pulse oximetry levels. 3. Apply the mask to the face with a snug fit. 4. Remove the mask for deep breathing exercises.

Answer 3 The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.

A client diagnosed with left pleural effusion has just been admitted for treatment. The nurse should plan to have which procedure tray available for use at the bedside? 1. Intubation 2. Paracentesis 3. Thoracentesis 4. Central venous line insertion

Answer 3 The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid from the pleural space, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case that the client's symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion. Options 1 and 4 are not specifically indicated for this procedure.

. The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk? 1. After the client eats lunch 2. After the client has a brief nap 3. After the client uses the metered-dose inhaler 4. After assessing the client's oxygen saturation

Answer 3 The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore, this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, the respiratory status of the client may not be at its best. Although monitoring oxygen saturation is appropriate, the intervention itself does not affect the client's respiratory function.

An adolescent is hospitalized with a diagnosis of Rocky Mountain spotted fever (RMSF). The nurse anticipates that which medication will be prescribed? 1. Ganciclovir 2. Amantadine 3. Doxycycline 4. Amphotericin B

Answer 3 The nursing care of an adolescent with RMSF includes the administration of doxycycline. An alternative medication is chloramphenicol. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat Parkinson's disease. Amphotericin B is used for fungal infections.

The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional intervention should the nurse be prepared to implement? 1. Assisting with arterial blood gases 2. Assisting with a lumbar puncture 3. Assessing cranial nerve functioning 4. Assessing respiratory rate and rhythm 5. Assessing pulmonary wedge pressure 6. Assessing cognitive abilities, including memory.

Answer 3, 4 Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brainstem injury because the respiratory center is located in the brainstem. Options 1, 2, 5, and 6 are not necessary based on the data in the question.

A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply. 1. Hypertension 2. Flat neck veins 3. Increased cyanosis 4. Tracheal deviation to the right 5. Diminished breath sounds on the left 6. Observable asymmetry of the thorax

Answer 3,4,5,6 A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, worsening cyanosis, and worsening dyspnea. The increased intrathoracic pressure causes the blood pressure to fall, not rise.

What should the nurse consider when determining whether a client diagnosed with a respiratory disease could tolerate and benefit from active progressive relaxation? Select all that apply. 1. Social status 2. Financial status 3. Functional status 4. Medical diagnosis 5. Ability to expend energy 6. Motivation of the individual

Answer 3,4,5,6 Active progressive relaxation training teaches the client how to effectively rest and reduce tension in the body. Some important considerations when choosing the type of relaxation technique are the client's physiological and psychological status. Because active progressive relaxation training requires a moderate expenditure of energy, the nurse needs to consider the client's functional status, medical diagnosis, and ability to expend energy. For example, a client with advanced respiratory disease may not have sufficient energy reserves to participate in active progressive relaxation techniques. The client needs to be motivated to participate in this form of alternative therapy to obtain beneficial results. The client's social or financial status has no relationship with her or his ability to tolerate and benefit from active progressive relaxation

During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition? 1. "Endometriosis is known as primary dysmenorrhea." 2. "Endometriosis is what causes me the pain that occurs when I ovulate." 3. "Endometriosis is the condition that has caused me to stop menstruating." 4. "Endometriosis means that I have uterine tissue growing outside my uterus."

Answer 4 Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes

Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period? 1. "Have you ever had heat exhaustion or heat stroke?" 2. "What is the normal range for your body temperature?" 3. "Do you or any of your family members have frequent infections?" 4. "Do you or any of your family members have problems with general anesthesia?"

Answer 4 Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.

The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item? 1. Tomato soup 2. Fresh fruit plate 3. Vegetable lasagna 4. Ground beef patty

Answer 4 : Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammoniacontaining foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, milk, peanut butter, and gelatin. The food items in options 1, 2, and 3 are acceptable to eat.

The nurse is assisting a client with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse should take which action to minimize the client's risk for injury? 1. Clamp the chest tube. 2. Call the primary health care provider. 3. Apply a petroleum gauze over the end of the chest tube. 4. Immerse the chest tube in a bottle of sterile water or normal saline.

Answer 4 : If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube or, in this case, immersing the end of the chest tube 1 to 2 inches below the surface of a 250-mL bottle of sterile water or normal saline until a new chest tube can be set up. The primary health care provider should be notified but only after taking corrective action. If the primary health care provider is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petroleum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest.

A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What should the nurse monitor to determine the presence of carbon monoxide poisoning? 1. Pulse oximetry 2. Urine myoglobin 3. Sputum carbon levels 4. Serum carboxyhemoglobin levels

Answer 4 : Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning, provide the level of poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity for binding with hemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated with 100% oxygen under pressure (hyperbaric oxygen therapy). Options 1, 2, and 3 would not identify carbon monoxide poisoning.

The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis? 1. Prednisone orally 2. Fludrocortisone orally 3. Spironolactone intramuscularly 4. Methylprednisolone sodium succinate intravenously

Answer 4 A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Spironolactone is a potassium-sparing diuretic

The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place? 1. Secure the electrodes with adhesive tape. 2. Place clear, transparent dressings over the electrodes. 3. Apply lanolin to the skin before applying the electrodes. 4. Cleanse the skin with alcohol before applying the electrodes.

Answer 4 Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.

A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first? 1. Call a code 2. Prepare for cardioversion 3. Prepare to defibrillate the client 4. Check the client's level of consciousness.

Answer 4 Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then cardiopulmonary resuscitation is initiated.

A client has been taking a prescribed calcium channel blocker therapy for approximately 2 months. The home care nurse monitoring the effects of therapy should determine that drug tolerance has developed if which is noted in the client? 1. Decrease in weight 2. Increased joint pain 3. Output greater than intake 4. Gradual rise in blood pressure

Answer 4 Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy. Joint pain is not associated with this form of tolerance.

The nurse reviews the arterial blood gas results of a client and notes the following: pH of 7.30 (7.30), Paco2 of 50 mm Hg (50 mm Hg), and bicarbonate (HCO3 ) of 22 mEq/L (22 mmol/L). The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Answer 4 Focus on the information in the question and the subject, interpreting arterial blood gas results. The normal pH is 7.35 to 7.45 (7.35 to 7.45). In a respiratory condition, an opposite effect will be seen between the pH and the Paco2 . In this situation, the pH is lower than the normal value, and the Paco2 is elevated. In an acidotic condition, the pH is low. Therefore, the values identified in the question indicate respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not normal, compensation has not occurred. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Paco2 as indicated in the question. Therefore, you can eliminate options 1 and 3. Also, remember that the pH decreases in an acidotic condition and compensation occurs, as evidenced by a normal pH. Remember that analysis is the second step in the nursing process! Review: steps for interpreting arterial blood gas results.

The nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively? 1. Cloudy sputum 2. Shallow breathing 3. Unilateral wheezing 4. Productive coughing

Answer 4 Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions for expectoration, via vital client participation in recovery. Cloudy sputum, shallow breathing, and wheezing indicate that the incentive spirometry is not effective because they point to infection, counterproductive depth of breathing, and bronchoconstriction, respectively

The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? 1. Dependent Edema 2. Diminished distal pulse 3. Coolness and pallor of skin 4. Presence of warm areas on the cast.

Answer 4 Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.

A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse should assess for which expected but adverse effect of PEEP? 1. Decreased peak pressure on the ventilator 2. Increased rectal temperature from 98° F to 100° F 3. Decreased heart rate from 78 to 64 beats per minute 4. Systolic blood pressure decrease from 122 to 98 mm Hg

Answer 4 PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. PEEP leads to increased intrathoracic pressure, which in turn leads to decreased cardiac output. This is manifested in the client by decreased systolic blood pressure and increased pulse (compensatory). Peak pressures on the ventilator should not be affected, although the pressure at the end of expiration remains positive at the level set for the PEEP. Fever indicates respiratory infection or infection from another source.

An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs? 1. Cooling effects of the cleansing agent 2. Client's adaptation to the air conditioning 3. Early clinical indicators of cardiogenic shock 4. Decline in sympathetic nervous system discharge

Answer 4 Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls. Options 1 and 2 are unrelated to the changes in vital signs. Because the client's vital signs remain within normal limits, the client exhibits no indication of cardiogenic shock.

An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety? 1. Covering the back dressing with a binder 2. Placing the infant in a head-down position 3. Strapping the infant in a baby seat sitting up 4. Elevating the head with the infant in the prone position

Answer 4 Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. Care of the operative site is carried out under the direction of the surgeon and includes close observation for signs of leakage of cerebrospinal fluid. The prone position is maintained after surgical closure to decrease the pressure on the surgical site on the back; however, many neurosurgeons allow side-lying or partial sidelying position unless it aggravates a coexisting hip dysplasia or permits undesirable hip flexion. This offers an opportunity for position changes, which reduces the risk of pressure sores and facilitates feeding. Elevating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity. If permitted, the infant can be held upright against the body with care taken to avoid pressure on the operative site. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site.

The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information should the nurse give the client about the postsurgical needs? 1. "You will need to undergo chemotherapy after surgery." 2. "You will need to wear an abdominal binder after surgery." 3. "You will not need any special long-term treatment after surgery." 4. "You will need to take daily hormone replacements beginning after the surgery."

Answer 4 The major cause of primary hyperaldosteronism is an aldosteronesecreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy require permanent replacement of adrenal hormones. Options 1, 2, and 3 are inaccurate statements regarding this surgery.

What action should the nurse take to assess the pharyngeal reflex on a child? 1. Ask the client to swallow 2. Pull down on the lower eyelid 3. Shine a light toward the bridge of the nose. 4. Stimulate the back of the throat with a tongue depressor.

Answer 4 The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas).

The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure? 1. Nebulizer 2. Ambu bag 3. Suction equipment 4. Incisional splinting pillow

Answer 4 The use of an incisional splint such as a "cough pillow" can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.

. Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel? 1. "Discontinue the medication immediately." 2. "Come to the clinic immediately for an assessment." 3. "I'll notify your primary health care provider of these results." 4. "This is a normal occurrence with the use of this medication."

Answer 4 Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.

The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated? 1. Strip the tubing and assess for a blood return. 2. Check the regional tissue for redness and warmth. 3. Increase the infusion rate and observe for swelling. 4. Gently palpate regional tissue for edema and coolness.

Answer 4 When assessing an IV for clinical indicators of infiltration, it is important to assess the site for edema and coolness, signifying leakage of the IV fluid into the surrounding tissues. Stripping the tubing will not cause a blood return but will force IV fluid into the surrounding tissues, which can increase the risk of tissue damage. Redness and warmth are more likely to indicate infection or phlebitis. Increasing the IV flow rate can further damage the tissues if the IV has infiltrated. Additionally, a primary health care provider's prescription is needed to increase an IV flow rate

The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply. 1. The client is sleeping soundly. 2. The client is awake and talking. 3. Respiratory rate is 26 breaths/minute. 4. The client's heart rate is 84 beats/minute. 5. Carboxyhemoglobin levels are less than 5%. 6. The heart monitor shows normal sinus rhythm.

Answer 4,5,6 Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.

The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply. 1. Wear knee-high hose to prevent edema. 2. Soak and wash the feet daily using cool water. 3. Use commercial removers for corns or calluses. 4. Use over-the-counter preparations to treat ingrown nails. 5. Apply lanolin or baby oil if dryness is noted along the feet. 6. Pat the feet dry thoroughly after washing and dry well between toes.

Answer 5,6 The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters

The nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. What information should the nurse include on the laboratory requisition? Select all that apply. 1. Ventilator settings 2. A list of client allergies 3. The date and time the specimen was drawn. 4. The date and time the specimen was drawn. 5. Any supplement oxygen the client is receiving. 6. Extremity from which the specimen was obtained.

Answer: 1, 3, 4, 5 An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn on room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. The client's allergies and the extremity from which the specimen was drawn do not have a direct bearing on the laboratory results.

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collect more information about the client's respiratory status.

Answer: 4 The oxygen is not increased without validation of the need for further oxygen and the approval of the health care provider. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry. Use the steps of the nursing process to answer correctly and remember that assessment is the first step. Also, use the ABCs—airway, breathing, and circulation—to direct you to option 4. Remember to look for strategic words! Review: care of the client with chronic obstructive pulmonary disease.

. The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement? 1. Allowing the client to complete the exercise program 2. Interrupting the client and weigh the client immediately 3. Interrupting the client and offer to take the client for a walk 4. Telling the client that he or she is not allowed to exercise rigorously

Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety

The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client? 1. Tinnitus 2. Burning in the ear 3. Itching in the affected ear 4. Severe pain in the affected ear

Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.