HESI TB Acute

The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse? A. Tall peak T waves on the cardiac monitor B. Peripheral pitting edema at 2 + indentation C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl D. Anuria for the last 12 hours.

D. Anuria for the last 12 hours.

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections.

D. Monitor for secondary infections

A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client's neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client's food allergy history

D. Obtain the client's food allergy history

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

D. Outline the area with ink and check it every 15 minutes to see if the area has increased

. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

D. Oxygen saturation

In early septic shock states, what is the primary cause of hypotension? A. Cardiac failure B. A vagal response C. Peripheral vasoconstriction D. Peripheral vasodilation

D. Peripheral vasodilation

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Onset of mild confusion B. Pain score 8 out of 10 C. Pale, diaphoretic skin D. Weak palpable distal pulses

D. Weak palpable distal pulses

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Determine client's pulse, blood pressure, and respirations

client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client's vital sign.

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin.

A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung.

1. The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take? · Ask the client if the stocking feel comfortable. · Supervise the UAP in the removal of the stockings. · Place a cover over the client's toes to keep them warm. · Discussed effective use of the stockings with the client on UAP

Discussed effective use of the stockings with the client on UAP · Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Distal pulse intensity

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?

Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)

Ease the client to the floor Loosen restrictive clothing Note the duration of the seizure

A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.

1. A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? · Cluster care to conserve energy · Initiate contact isolation · Encourage him to use an electric razor · Asses him for adventitious lung sounds

Encourage him to use an electric razor · Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding.

A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?

Encourage screening for a peptic ulcer

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?

Ensure proper alignment of the leg in traction.

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

Further evaluation involving surgery may be needed

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? Resume normal physical activity Drink electrolyte fluid replacement Give a dose of regular insulin per sliding scale Measure urinary output over 24 hours.

Give a dose of regular insulin per sliding scale Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale.

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? Lactate Glucose Hemoglobin Creatinine

Glucose

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done.

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? Hypokalemia Ketonuria. Peripheral edema Elevated blood pressure

Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias.

When implementing a disaster intervention plan, which intervention should the nurse implement first? Initiate the discharge of stable clients from hospital units Identify a command center where activities are coordinated Assess community safety needs impacted by the disaster Instruct all essential off-duty personnel to report to the facility

Identify a command center where activities are coordinated

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child's diaper more often.

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? Jaundice Nausea Fever Fatigue

Jaundice

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma

The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration Abrasion Contusion Ulceration

Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.

The nurse caring for a client with acute renal failure (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Large amounts of fluid and electrolyte replacement.

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

Listen with the bell at the same location

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Maintain both lower extremities elevated on pillows.

A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

Maintain contact transmission precaution

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?

Maintain contact transmission precautions

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) Monitor abdominal girth. Increase oral fluid intake to 1500 ml daily. Report serum albumin and globulin levels. Provide diet low in phosphorous. Note signs of swelling and edema.

Monitor abdominal girth. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) Monitor abdominal girth. Increase oral fluid intake to 1500 ml daily. Report serum albumin and globulin levels. Provide diet low in phosphorous. Note signs of swelling and edema.

Monitor abdominal girth. Report serum albumin and globulin levels Note signs of swelling and edema. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma.

1. A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) · Monitor heart, lung, and kidney function. · Notify healthcare provider of serum amylase and lipase levels. · Review client's abdominal ultrasound findings. · Position client on abdomen to provide organ stability · Encourage an increased intake of clear oral fluids

Monitor heart, lung, and kidney function. · Notify healthcare provider of serum amylase and lipase levels. · Review client's abdominal ultrasound findings.

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? Multiple organ dysfunction syndrome (MODS) Disseminated intravascular coagulation (DIC) Chronic obstructive disease. Acquired immunodeficiency syndrome (AIDS)

Multiple organ dysfunction syndrome (MODS) Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment contact precautions droplet precautions protective environment

Negative pressure environment

One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?

Neurovascular and circulation compromise related to compartment syndrome.

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

New onset of purple skin lesions.

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? "I have a headache that gets worse when I sit up" "I am having pain in my lower back when I move my legs" "My throat hurts when I swallow" "I feel sick to my stomach and am going to throw up"

"I have a headache that gets worse when I sit up"

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia

1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia

1. A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last) 1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

1. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? · Observe neck for jugular vein distention · Notify healthcare provider to prepare for pericardiocentesis · Asses for paradoxical blood pressure · Monitor oxygen saturation (Sp02) via continuous pulse oximetry

Notify healthcare provider to prepare for pericardiocentesis · Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Notify the healthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care.

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? Increased Glasgow coma scale score. Nuchal rigidity and papilledema. Confusion and papilledema Periorbital ecchymosis. Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

Nuchal rigidity and papilledema. Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? Observe aspiration site. Assess body temperature Monitor skin elasticity Measure urinary output

Observe aspiration site.

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Observe for unilateral swelling

1. A client is complaining of intermittent, left, lower abdominal pain that began two days ago...implement the following interventions? · Correct orders: (DPIA) 1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants

1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia

1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia

1. The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first? ·

Observe the amount of urine in the client's urinary drainage bag

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Observe the antecubital fossa for inflammation.

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? 9 % 18 % 36 % 45 %

36 % Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect.

The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for relief of severe dysmenorrhea. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A) Oral contraceptives increase the symptoms of endometriosis. B) The symptoms of endometriosis can increase with menopause. C) An option to diagnose disease extent and provide therapeutic treatment is laparoscopy. D) Infertile is successfully treated with removal of intra-abdominal endometrial lesions.

A) Oral contraceptives increase the symptoms of endometriosis.

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? A. Ensure client takes a diuretic q AM B. Obtain serum creatinine levels daily C. Measure ankle circumference D. Monitor daily sodium intake

A. Ensure client takes a diuretic q AM

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

A. Fresh turkey slices and berries D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. .

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis

The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Administer a prescribed analgesia for pain.

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim) Aspirin, low dose Furosemide (lasix) Enalapril (vasote)

Allopurinol (Zyloprim)

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? Antibiotics Anticoagulants Antihypertensive Anticholinergics

Antibiotics

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? · Auscultate all quadrant of the abdomen. · Perform a digital rectal exam · Palpate the liver and spleen · Obtain a hemoccult of the client's stool

Auscultate all quadrant of the abdomen.

The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds Observe for edema around the ankles Measure the client's capillary glucose level Count the apical and radial pulses simultaneously

Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds

1. A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? · Engage in physical exercise immediately after eating to help decrease cholesterol levels. · Walk briskly in cold weather to increase cardiac output · Keep nitroglycerin in a light-colored plastic bottle and readily available. · Avoid all isometric exercises, but walk regularly.

Avoid all isometric exercises, but walk regularly · Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. "Have you had a heart attack in the last 6 months" B. "Have you had any difficulty in starting your urinary stream" C. "Have you taken any antibiotics recently" D. "Have you received any blood products in the last year"

B. "Have you had any difficulty in starting your urinary stream"

The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantom pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies.

B. A client who is receiving a continuous tube feeding and is now vomiting.

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? A. This medication will coat the lining of your esophagus B. Antacids will neutralize the acid in your stomach C. It will improve the emptying of food through your stomach D. antacids decrease the production of gastric secretions

B. Antacids will neutralize the acid in your stomach

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding

B. Appearance of wound

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

B. Elevated blood pressure must be anticipated and identified quickly

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B. Furosemide

A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain? A. Use of sleeping medications. B. History of alcohol use, C. Use of antianxiety medications, D. History of this behavior.

B. History of alcohol use,

After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.

B. Notify the HCP of the results.

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. Obtain a chest X-ray per protocol. B. Place a mask on the client's face. C. Assess the client's temperature. D. Determine the client's blood pressure

B. Place a mask on the client's face.

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber

B. Plastic tubing located at the chest insertion site

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? Be alert for possible cross-sensitivity to cephalosporin agents.

Be alert for possible cross-sensitivity to cephalosporin agents.

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? Administer antiemetic agents Bivalve the cast for distal compromise Provide high- calorie, high-protein diet Begin parenteral antibiotic therapy

Begin parenteral antibiotic therapy Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.

C. Give IV dose of adenosine rapidly over 1-2 seconds.

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level D. Administer PRN antianxiety medication.

C. Review the client's serum calcium level

After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? Capillary refill of 8 seconds bruises on arms and legs round and tight abdomen pitting edema in lower legs

Capillary refill of 8 seconds Rational: Dehydration, hypothermia and most types of shock cause a sluggish or prolonged capillary refill time that is greater than 2 seconds.

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? Cardiac rhythm and heart rate. Daily intake of foods rich in potassium. Hourly urinary output Thirst ad skin turgor.

Cardiac rhythm and heart rate.

During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Check the client for lacerations or fractures

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? Cleanse the foot with soap and water and apply an antibiotic ointment Provide teaching about the need for a tetanus booster within the next 72 hours. have the mother check the child's temperature q4h for the next 24 hours transfer the child to the emergency department to receive a gamma globulin injection

Cleanse the foot with soap and water and apply an antibiotic ointment

The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Clear fluid leaking from the nose.

1. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? · Finger stick blood glucose 120 mg/dL post exchange · Arteriovenous (AV) graft surgical site pulsations. · Anorexia and poor intake of adequate dietary protein · Cloudy dialysate output and rebound abdominal pain

Cloudy dialysate output and rebound abdominal pain

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) Collect multiple site screening culture for MRSA Call healthcare provider for a prescription for linezolid (Zyrovix) Place the client on contact transmission precautions Obtain sputum specimen for culture and sensitivity Continue to monitor for client sign of infection.

Collect multiple site screening culture for MRSA Place the client on contact transmission precautions Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated9D) based on the client's history is a wound infection.

When evaluating a client's rectal bleeding, which findings should the nurse document?

Color characteristics of each stool.

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Confirm the necessity for continued use of the CVC.

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?

Oliguria signals tubular necrosis related to hypoperfusion

In early septic shock states, what is the primary cause of hypotension? Peripheral vasoconstriction Peripheral vasodilation Cardiac failure A vagal response

Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II Persistent coughing while drinking Unilateral facial drooping Inappropriate or exaggerated mood swings

Persistent coughing while drinking

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula Initiate bag- valve mask ventilation. Begin cardiopulmonary resuscitation

Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?

Provide daily care of tong insertion sites using saline and antibiotic ointment

1. While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Raise the client's legs and feet

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Raise the head of the bed to a Fowler's position and support his arms with a pillow

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness.

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual papanicolaou (Pap) smears.

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Report any signs of cloudy urine output.

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?

Respiratory apnea of 30 seconds

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: Restlessness Clenched Fist Increased pulse rate Increased respiratory rate. Increased temperature Peripheral pallor of the skin

Restlessness Clenched Fist Increased pulse rate Increased respiratory rate. Pyloromyotomy is surgery to widen your baby's pylorus. The pylorus is the opening between your baby's stomach and intestine. He or she may have trouble eating if the opening is too narrow (a condition called stenosis).

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Ask the UAP to take the blood pressure in the other arm Tell the UAP to use a different sphygmomanometer. Review the client's serum calcium level Administer PRN antianxiety medication.

Review the client's serum calcium level Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.

Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? Send stool sample to the lab for a guaiac test Observe stool for a clay-colored appearance. Obtain specimen for culture and sensitivity analysis Asses for fatty yellow streaks in the client's stool.

Send stool sample to the lab for a guaiac test Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.

A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? capillary glucose urine specific gravity Serum calcium white blood cell count

Serum calcium

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L).

A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? Infection Increase intracranial pressure Shock Head Injury.

Shock

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Stop the normal saline infusion.

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Stroke secondary to hemorrhage

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Tell all their assigned clients to stay in their rooms.

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? The client's previous GCS score When the client's stroke symptoms started If the client is oriented to time The client's blood pressure and respiration rate

The client's previous GCS score Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client's condition

1. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? · The client is too obese · Palpating in the wrong abdominal quadrant · Deeper palpation technique is needed · The gallbladder is normal

The gallbladder is normal · Rationale: a normal healthy gallbladder is not palpable

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? working together can decrease the risk for back injury The technique is intended to maintain straight spinal alignment. Using two or three people increases client safety. turning instead of pulling reduces the likelihood of skin damage

The technique is intended to maintain straight spinal alignment.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm to promote retraction of the intercostal accessory muscle of respiration to promote bronchodilation and effective airway clearance to decrease pressure on the medullary center which stimulates breathing

To reduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing.

The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. · Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.

A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors.

Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client?

Use two forms of contraception while taking this drug.

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? Tachycarcia Dyspnea Vomiting Muscle cramps

Vomiting

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? Weigh every morning Eat a high protein diet Perform range of motion exercises Limit fluid intake to 1,500 ml daily

Weigh every morning

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity

The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?

compartment syndrome is the result of swelling and subsequent reduction in circulation to the area distal to the compartment. This can be a complication of traumatic injury and cast administration, so it is important to assess circulation distal to the casted prolonged capillary refill.

1. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis?

· "I couldn't get my son's socks and shoes on this morning"

1. A nurse working on an endocrine unit should see which client first? · An adolescent male with diabetes who is arguing about his insulin dose. · An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). · An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. · A client taking corticosteroids who has become disoriented in the last two hours.

· A client taking corticosteroids who has become disoriented in the last two hours. · Rational: meeting the client's need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first.

1. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? · A collapsed lung · A history of COPD · A chronic lung infection · Normally functioning lungs

· A collapsed lung

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply

· A slice of whole grain toast · A bowl of cream of wheat

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

· A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

1. A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

· Administered Nebulized Epinephrine

1. A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

· Allow the infant to rest before feeding

1. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? · Altered consciousness within the first 24 hours after injury. · Cushing reflex and cerebral edema after 24 hours · Fever, nuchal rigidity and opisthotonos within hours · Headache and pupillary changes 48 hours after a head injury

· Altered consciousness within the first 24 hours after injury.

Which class of drugs is the only source of a cure for septic shock?

· Anti-infective

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

· Ask the client about gastrointestinal pain

1. The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question? · Aspirin content. · Dose · Route · Risk for addiction

· Aspirin content.

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

· Asses for contraindications for thrombolytic therapy

1. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? · Arrange transport for admission to the hospital. · Insert saline lock for IV diuretic therapy. · Assess compliance with routine prescriptions. · Instruct the client to monitor daily caloric intake.

· Assess compliance with routine prescriptions. · Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)

1. The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply

· Assess the client for self-care ability · Provide pain medication instructions · Teach care of ostomy to care provider

1. A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?

· Auscultate bowel sounds in all four quadrants

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? · Monitor daily sodium intake. · Record usual eating patterns. · Measure ankle circumference. · Auscultate for irregular heart rate.

· Auscultate for irregular heart rate. · Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.

1. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? · Review the heart rhythm on cardiac monitors · Check urinary catheter for obstruction · Auscultated bilateral breath sounds · Give PRN dose of lorazepam (Ativan)

· Auscultated bilateral breath sounds · Rationale: Restlessness often results from decreased oxygenation so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.

1. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? · Limit intake fatty foods for one month after surgery. · Notify the healthcare provider if edema occurs. · Increase activity and exercise gradually, as tolerated. · Avoid crowds for first two months after surgery.

· Avoid crowds for first two months after surgery. · Rationale: Cyclosporine immunosuppression therapy is vital in the success of liver transplantation and can increase the risk for infection, which is critical in the first two months after surgery. Fever is often.

1. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? · Adhere to a bland diet whenever planning to eat out · Decrease fluid intake at meal times · Avoid foods that caused gas before the colostomy Eliminate foods high in cellulose

· Avoid foods that caused gas before the colostomy

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

· Begin manual ventilation immediately.

1. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? · Blood pressure 170/98 · Joint and muscle aches · Urine output 300 ml/hr · Dark, rust-colored urine

· Blood pressure 170/98

1. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? · Perform CPT after meals to increase appetite and improve food intake. · CPT should be performed more frequently, but at least an hour before meals. · Stop using CPT during the daytime until the child has regained an appetite. · Perform CPT only in the morning, but increase frequency when appetite improves.

· CPT should be performed more frequently, but at least an hour before meals. · Rationale: CPY with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

1. Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? · Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema · A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS · Functional residual capacity and lung compliance increase as the disease progresses · Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema

· Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

1. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? · Check the TPN solution for cloudiness · Attach the IV tubing to the central line · Set the infusion pump at the prescribed rate · Prime the IV tubing with TPN solution

· Check the TPN solution for cloudiness

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

· Chest pain and dysrhythmia

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

· Chest physiotherapy should be performed twice a day before a meal.

1. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? · Measure the child's abdominal girth · Perform an otoscopic examination · Collect a urine specimen for routine urinalysis · Obtain a blood specimen for serum electrolytes

· Collect a urine specimen for routine urinalysis

A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

· Complete pre-infusion checklist

1. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? · Confusion and tremors · Yellowing and itching of skin. · Abdominal pain and vomiting · Anorexia and abdominal distention

· Confusion and tremors · Rationale: daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action.

1. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

· Contact the healthcare provider immediately to report the laboratory value regardless of the advice

1. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? · Serum albumin · Creatinine level · Culture for sensitive organisms. · Serum blood glucose (BG) level

· Culture for sensitive organisms. · RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client's laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.

1. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? · Check the client's temperature, blood sugar, and urine output. · Transport the client for laboratory client for laboratory test and electrocardiogram (EKG) · Delegate care of the crying client to an unlicensed assistant · Send the client to the shelter's nutrient center to obtain water and food.

· Delegate care of the crying client to an unlicensed assistant · Rationale: According to the simple triage and Rapid Treatment (START) protocol of triage, the nurse should determine which client fit the objective of providing the greatest good for the greatest number of people who are most likely to survive. Delegating the care of the crying person to an unlicensed assistant allow the nurse to care for the injured who require intervention based on their ability to breath, maintain circulation and follow simple commands. A and B are not indicated at this time. Although food and water may be indicative, the woman's distress should not be dismissed by sending her to the shelter alone.

1. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? · Call poison control emergency number. · Determine type of chemical exposure. · Obtain equipment for gastric lavage. · Assess child for altered sensorium.

· Determine type of chemical exposure · Rational: once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested

1. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? · Diabetic ketoacidosis and titrated IV insulin infusion · Emphysema extubated 3 hours ago receiving heated mist · Subdural hematoma with an intracranial monitoring device Acute coronary syndrome treated with vasopressors

· Diabetic ketoacidosis and titrated IV insulin infusion

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide?

· Dialysis would need to be resumed if chronic rejection becomes a reality

1. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? · Range of Motion · Distal pulse intensity · Extremity sensation · Presence of exudate

· Distal pulse intensity · Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment do not have the priority of determining perfusion to the extremity.

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

· Document the extend of the bruising in the medical record

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

· Does your pain occur when walking short distances?

To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement? · Dress each wound separately. · Avoid sharing equipment between multiple clients. · Use gown, mask and gloves with dressing change. · Implement protective isolation.

· Dress each wound separately. · Rational: each wound should be dressed separately using a new pair of sterile glove to avoid auto contamination (the transfer of microorganisms form one infected wound to a non-infected wound). The other choices do not prevent auto contamination.

1. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? · Dyspnea, cough, and fatigue. · Hepatomegaly and distended neck veins · Pain over the pericardium and friction rub. · Narrowing pulse pressure and distant heart sounds.

· Dyspnea, cough, and fatigue.

1. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? · Decreased white blood cell count · Pruritus and muscle aches · Elevated liver function tests · Vomiting and diarrhea

· Elevated liver function tests · Rationale: Elevated liver function enzymes are a serious side effect of antivirals and should be reported. A decrease white blood count is a consistent finding with shingle B and (C and D) are side effects that affect that are of less priority than A.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

· Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

1. After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

· Epinephrine Injection, USP IV

1. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? · Evaluate closest proximal pulse. · Asses skin elasticity of the stump. · Observe for swelling around the stump. · Note amount color of wound drainage.

· Evaluate closest proximal pulse. · Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

· Evaluate daily blood clotting factors.

1. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? · Patch one eye. · Reorient often. · Range of motion. · Evaluate swallow

· Evaluate swallow · Rational: Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH. Difficulty swallowing due to brainstem nerve damage should be care, but determining the client's risk for aspiration is most important.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

· Evaluate the oxygen saturation

1. A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

· Evaluate the urine osmolality and the serum osmolality values.

1. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? · Explain that counseling will be provided to give her information about her cancer risk · Gather additional information about the client's family history for all types of cancer. · Offer assurance that there are a variety of effective treatments for breast cancer. · Provide information about survival rates for women who have this genetic mutation.

· Explain that counseling will be provided to give her information about her cancer risk · Rational: BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A)to the client along with options for increased screening or preventative measures. (B) Is completed by the genetic counselor before the client undergoes genetic testing. a positive BRACA1test is not an indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling.

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

· Expresses an understanding of the procedure.

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

· Fresh horseradish

1. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? · Loud hallway noise. · Fever · Full bladder · Frequent cough.

· Full bladder · Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)

· Headache and tremors · Postural hypotension · Pallor and diaphoresis · Irregular heart beat

1. A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

· Human source grafts require monitoring for signs of graft rejection

1. A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

· Hyperextended with neck supported by a rolled towel.

1. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? · Hypernatremia · Excessive thirst · Elevated heart rate · Poor skin turgor

· Hypernatremia

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?

· Hypocapnea reduces ICP

1. A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? · Hypotension. · Fever and chills · Dizziness · Headache

· Hypotension.

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? · Early treatment is very effective · I will clean my hot tub better · These warts are caused by a fungus · I need to have regular pap smears

· I need to have regular pap smears

1. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? · Increase the oxygen flow via nasal cannula if dyspnea is present. · Place in a Trendelenburg position to increase cerebral blood flow · Monitor capillary glucose measurements hourly during transfusion. · Encourage increased intake of oral fluid to improve skin turgor.

· Increase the oxygen flow via nasal cannula if dyspnea is present.

1. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? · Report the results to the healthcare provider. · Increase ventilator rate. · Administer a dose of sodium carbonate. · Decrease the flow rate of oxygen.

· Increase ventilator rate. · Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

· Ineffective coping related to denial

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement?

· Infuse a rapid IV normal saline bolus

1. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

· Infuse sodium chloride 0.9% (normal saline)

1. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? · The intravenous fluid replacement contains a hypertonic solution of sodium chloride · Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst · Insensible loss of body fluids contributes to the hemoconcentration of serum solutes · Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

· Insensible loss of body fluids contributes to the hemoconcentration of serum solutes · Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

1. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) · Inspect skin for redness · Use a residual limb shrinker · Apply alcohol to the stump after bathing · Wash the stump with soap and water · Avoid range of motion exercises

· Inspect skin for redness · Use a residual limb shrinker · Wash the stump with soap and water · Rationale: Several actions are recommended for home care following an amputation. The skin should be inspected regularly for abnormalities such as redness, blistering, or abrasions. A residual limb shrinker should be applied over the stump to protect it and reduce edema. The stump should be washed daily with a mild soap and carefully rinse and dried. The client should avoid cleansing with alcohol because it can dry and crack the skin. Range of motion should be done daily.

1. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? · Ask a family member to sit with the client · Apply bilateral soft wrist restraints · Assign staff to check client q15 minutes · Install a bed exit safety monitoring device

· Install a bed exit safety monitoring device

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

· Instruct the client to keep the left leg straight · Observe the insertion site for a hematoma · Circle first noted drainage on the dressing

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

· Instruct the client to keep the left leg straight · Observe the insertion site for a hematoma · Circle first noted drainage on the dressing

The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? · Irregular pulse · Tachycardia · Chest pain · Urinary frequenc

· Irregular pulse

1. The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug? · It blocks the effects of histamine, causing decreased secretion of acid · Ranitidine will neutralize gastric acid and decrease gastric pH · This drug provides a protective coating over the gastric mucosa · It effectively blocks 97% of the gastric acid secreted in the stomach

· It blocks the effects of histamine, causing decreased secretion of acid

1. An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? · Lethargy · Decorticate posturing · Fixed dilated pupil · Clear drainage from the ear.

· Lethargy · Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP.

1. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? · Level of consciousness · Percussion of abdomen · Serum electrolytes · Blood glucose.

· Level of consciousness · Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and metal status.

1. When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? · High protein · Low fat · Low sodium · High carbohydrate.

· Low fat · Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.

1. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client?

· Magnesium hydroxide (Maalox)

1. A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

· Maintain strict aseptic technique.

1. What is the nurse's priority goal when providing care for a 2-year-old child experiencing a seizure · Stop the seizure activity · Decrease the temperature · Manage the airway · Protect the body from injury

· Manage the airway

1. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) · Check urine for ketones · Measure blood glucose · Monitor vital signs · Assessed level of consciousness · Obtain culture of wound

· Measure blood glucose · Monitor vital signs · Assessed level of consciousness · Rationale: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS.

1. While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? · Apply a pressure dressing around the chest tube insertion site. · Assess the client for allergies to topical cleaning agents. · Measure the area of swelling and crackling. · Administer an oral antihistamine per PRN protocol.

· Measure the area of swelling and crackling. · Rational: a crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured and the finding documented. Other options are not indicated for crepitus.

1. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? · Monitor for an elevated temperature · Measure the abdominal girth daily · Report the onset of sclera jaundice · Keep a record of daily urinary output

· Monitor for an elevated temperature · Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

· Monitor mental status.

1. Which intervention should the nurse include in the plan of care for a client with leukocytosis? · Avoid intramuscular injections · Monitor temperature regularly · Assess skin for petechiae or bruising · Implement protective isolation measures

· Monitor temperature regularly

1. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? · Monitor the client's cardiac activity via telemetry. · Maintain venous access with an infusion of normal saline. · Assess glucose via fingerstick q4 to 6 hours. · Evaluate hourly urine output for return of normal renal function.

· Monitor the client's cardiac activity via telemetry. · Rational: as insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias related to abnormal serum potassium levels. IV access, assessment of glucose level, and monitoring urine output are important interventions, but do not have the priority of monitoring cardiac function.

1. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? · Monitor urine output hourly. · Assess for back muscle aches · Record drainage from drain · Obtain body weight daily

· Monitor urine output hourly.

1. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

· Move obstacle away from client · Monitor physical movements · Observe for a patent airway · Record the duration of the seizure

1. A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? · Expiratory stridor and nasal flaring · Mucous membranes cherry red color · Carbonaceous particles in sputum · Pulse oximetry reading of 80 percent

· Mucous membranes cherry red color

1. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? · Jaundice skin tone · Muffled heart sounds · Pitting peripheral edema · Bilateral scleral edema

· Muffled heart sounds · Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.

1. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? · Insomnia · Muscle cramping · Increase appetite · Anxiety.

· Muscle cramping · Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.

1. A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement? · Negative pressure environment · Contact precautions · Droplet precautions · Protective environment

· Negative pressure environment

1. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

· Neurologically stable without indications of an increased ICP

1. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

· Notify the employee health nurse.

1. A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?

· Notify the healthcare provider and obtain a tracheostomy tray

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)...which breakfast selection by the client indicates effective learning?

· Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

1. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? · Evaluate the client's ability to use an incentive spirometer · Monitor the amount of drainage from the client's incision · Observe both lower extremities for redness and swelling · Palpate all peripheral pulse points for volume and strength

· Observe both lower extremities for redness and swelling · Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis.

1. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? · Determine client's level current blood alcohol level. · Observe for changes in level of consciousness. · Involve the client's family in healthcare decisions. · Provide grief counseling for client and his family.

· Observe for changes in level of consciousness. · Rationale: Based on the client's history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.

1. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? · Collect a clean catch urine specimen. · Instruct the client to empty the bladder. · Obtain vital signs and breath sounds. · No specific nursing action is required

· Obtain vital signs and breath sounds. · Rational: the client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication.

1. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? · Obtain a urine specimen for culture and sensitivity · Palpate the client's suprapubic area for distention · Advise the client to maintain a voiding diary for one week · Instruct in effective technique to cleanse the glans penis

· Palpate the client's suprapubic area for distention · Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.

1. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? · Abnormal responses for cranial nerves I and II · Persistent coughing while drinking · Unilateral facial drooping · Inappropriate or exaggerated mood swings

· Persistent coughing while drinking

1. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and thready. What action should the nurse take? · Document that an accurate oxygen saturation reading cannot be obtained · Elevate to client's hands for five minutes prior to obtaining a reading from the finger · Increase the oxygen based on the clients breathing patterns and lung sounds · Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

· Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading · Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.

1. Which intervention should the nurse implement for a client with a superficial (first degree) burn?

· Place wet cloths on the burned areas for short periods of time.

1. A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? · Review record of recent analgesia · Provide frequent pulmonary toilet · Prepare the client for intubation · Obtain STAT arterial blood gases

· Prepare the client for intubation

1. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? · Administer epinephrine IV · Give an IV bolus of amiodarone · Provide immediate defibrillation · Prepare for synchronized cardioversion

· Provide immediate defibrillation

1. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? · Provide supplemental oxygen · Auscultate bilateral lung fields · Administer a nebulizer treatment · Reinforce occlusive CT dressing · Give PRN dose of pain medication

· Provide supplemental oxygen · Auscultate bilateral lung fields · Reinforce occlusive CT dressing · Rationale: the air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.

1. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? · Tinea corporis · Herpes zoster · Psoriasis · Drug reaction

· Psoriasis

1. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? · Rebound tenderness in the upper quadrants · Hypoactive bowel sounds in the lower quadrants · Tympany with percussion of the abdomen · Light colored gastric aspirate via the nasogastric tube

· Rebound tenderness in the upper quadrants

1. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond? · Replace the dressing and remove the drainage device · Reposition the drainage device and keep the plug open · Notify the healthcare provider that the drain is not working · Recompress the wound suction device and secure to plug

· Recompress the wound suction device and secure to plug · Rationale: The plug of a wound suction device, such as a Hemovac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated.

1. Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? · Maintain adequate cardiac output · Promote adequate tissue perfusion · Promote rest and sleep · Reduce the risk for injury

· Reduce the risk for injury

1. The nurse is preparing to discharge an older adult female client who is at risk for hypocalcemia...nurse include with this client's discharge teaching? · Report any muscle twitching or seizures · Take vitamin D with calcium daily · Low fat yogurt is a good source of calcium · Keep a diet record to monitor calcium intake · Avoid seafood, particularly selfish

· Report any muscle twitching or seizures · Take vitamin D with calcium daily · Low fat yogurt is a good source of calcium · Keep a diet record to monitor calcium intake

The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client...

· Report fresh blood in the urine

1. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply). · Apply soft upper limb restrains and raise all four bed rails · Report mental status change to the healthcare provider · Assess the client's breath sounds and oxygen saturation · Assign the UAP to re-assess the client's risk for falls · Review the client's most recent serum electrolyte values

· Report mental status change to the healthcare provider · Assess the client's breath sounds and oxygen saturation · Review the client's most recent serum electrolyte values · Rationale: The healthcare provider should be informed of changes in the client's condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP (D).

1. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? · Reposition the infant every 2 hours. · Perform diaper changes under the light. · Feed the infant every 4 hours. · Cover with a receiving blanket.

· Reposition the infant every 2 hours. · Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy.

1. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? · Research indicates that mirror therapy is effective in reducing phantom limb pain · You can try mirror therapy, but do not expect to complete elimination of the pain · Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective · Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

· Research indicates that mirror therapy is effective in reducing phantom limb pain · Rationale: pain relief associated with mirror therapy may be due to the activation of neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain.

1. A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

· Schedule the client for the chest radiograph · Obtain sputum for acid fast bacillus (AFB) testing · Place a mask on the client until he is moved to isolation.

In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

· Serum creatinine

1. An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? · Serum potassium · Urine ketones · Urine albumin · Serum protein

· Serum potassium

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? · Examine the victim's body surfaces for arterial bleeding · Stabilize the victim's neck and roll over to evaluate his status · Return to the car to call emergency response 911 for help · Open the airway and initiate resuscitative measures

· Stabilize the victim's neck and roll over to evaluate his status

1. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? · Stop the transfusion start a saline · Observe for a maculopapular rash · Report the fever to the blood bank · Give a PRN dose of acetaminophen

· Stop the transfusion start a saline

1. Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? · Sudden dysphagia · Blurred visual field · Gradual weakness · Profuse diarrhea

· Sudden dysphagia

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

· Surgeon needs to see client immediately to evaluate the situation

1. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care? · Encourage Progressive active range of motion · Teach need for dietary and supplementary vitamin D3 · Explain the need for skin exposure to sunlight without sunscreen · Instruct the client to use of muscle strengthening exercises

· Teach need for dietary and supplementary vitamin D3 · Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normal-appearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.

1. The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

· Tell the staff to keep all clients and visitors in the client rooms with the doors closed

1. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? · The client has asymmetrical chest wall expansion · The clients complain of pain at the insertion site · The client chest's x-ray indicates decreased pleural effusion · The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

· The client has asymmetrical chest wall expansion · Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.

1. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

· The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease. · Rationale: Carafate coats the mucosal lining prior to eating a meal

1. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? · Lorazepam (Ativan) · Famotidine (Pepcid) · Thiamine (Vitamin B1) · Atenolol (Tenormin)

· Thiamine (Vitamin B1) · Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.

1. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? · Thready brachial pulse. · Respirations of 24/minute · Right foot cool to touch · Swelling at the site of injury

· Thready brachial pulse.

1. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? · Two days postoperative bladder surgery with continuous bladder irrigation infusing. · One day postoperative laparoscopic cholecystectomy requesting pain medication. · Three days postoperative colon resection receiving transfusion of packed RBCs. · Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

· Three days postoperative colon resection receiving transfusion of packed RBCs.

1. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? · Irrigate the indwelling urinary catheter. · Prepare the client for external pacing. · Obtain capillary blood glucose measurement. · Titrate the dopamine infusion to raise the BP.

· Titrate the dopamine infusion to raise the BP. · Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client's capillary blood glucose should be monitored, but is not directly indicated at this time.

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? · High salt can damage the lining of the blood vessels · Too much salt can cause the kidneys to retain fluid · Excessive salt can cause blood vessels to constrict · Salt can cause information inside the blood vessels

· Too much salt can cause the kidneys to retain fluid · Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.

1. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) · Topical corticosteroid. · Topical scabicide. · Topical alcohol rub. · Transdermal analgesic. · Oral antihistamine

· Topical corticosteroid. · Oral antihistamine · Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated.

1. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? · Continuous bubbling in the water seal chamber · Decrease bright red blood drainage · Tachypnea and difficulty breathing · Tracheal deviation toward the left lung.

· Tracheal deviation toward the left lung. · Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax.

Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? · Transfuse Type A negative blood until type AB negative is available. · Recheck the client's hemoglobin, blood type and Rh factor. · Administer normal saline solution until type AB negative is available · Obtain additional consent for administration of type A negative blood

· Transfuse Type A negative blood until type AB negative is available. · Rationale: those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client's hemoglobin is critically low and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation.

1. Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

· Transfuse packed red blood cells

1. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions? · Turkey salad sandwich. · Clam chowder · Macaroni and cheese · Bacon, lettuce, and tomato sandwich

· Turkey salad sandwich.

1. After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.) · Unrelieved back and flank pain. · Quarter-size red drainage at site · Cool and pale left leg and foot. · Tenderness over insertion site · Left groin egg-size hematoma.

· Unrelieved back and flank pain. · Cool and pale left leg and foot. · Left groin egg-size hematoma.

1. A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

· Unresponsive to painful stimuli

1. A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

· Urinary output of 25mL per hour

1. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? · Use a secondary port of the Normal Saline solution to administer the antibiotic. · Add the antibiotic to the TPN solution, and continue the normal saline solution. · Stop the TPN infusion for the time needed to administer the prescribed antibiotic. · Add the antibiotic to the Normal Saline solution and continue both infusions.

· Use a secondary port of the Normal Saline solution to administer the antibiotic. · Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.

1. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? · Wash hands frequently · Avoid drinking lake water · Wear long sleeves and pants · Do not share personal products

· Wear long sleeves and pants · Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.

1. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? · Withhold food and fluid intake. · Initiate IV fluid replacement. · Administer antiemetic as needed. · Evaluate intake and output ratio.

· Withhold food and fluid intake. · Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

1. When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? · Yogurt. · Processed cheese. · Nuts · Fresh turkey · Fresh chicken

· Yogurt. · Processed cheese. · Rational: Rich in Calcium and vitamin D

1. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? · creatinine clearance 25 mL/ minute (normal 80-135) · calcium 9 mg/dl · hemoglobin 12 grams/dl · partial thromboplastin time (PTT) 30 seconds

· creatinine clearance 25 mL/ minute (normal 80-135)

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? · creatinine clearance 25 mL/ minute (normal 80-135) · calcium 9 mg/dl · hemoglobin 12 grams/dl · partial thromboplastin time (PTT) 30 seconds

· creatinine clearance 25 mL/ minute (normal 80-135)

1. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? · infectious process · metastatic process · autoimmune disorder · inflammatory disorder

· infectious process

1. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? · Rebound abdominal tenderness · nausea and projectile vomit · rib pain with deep inspiration · diminished bilateral breath sounds

· nausea and projectile vomit · Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.

1. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? · Evaluate postural blood pressure measurements · Obtain specimen for uranalysis · Encourage popsicles and fluids of choice · Assess bowel sounds in all quadrants

·· Encourage popsicles and fluids of choice Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.