Med-Surg Exam 1

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? "I must cover my facial hair." "I don't need a sterile gown to be in the OR." "If I go into the OR, I must wear a protective mask." "My scrubs are sterile."

"My scrubs are sterile." Scrub attire is provided by the hospital and is clean, not sterile. All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile they may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

"Pain medication.." - Pain medication will minimize pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? "Are you Mr. Smith?" "Good morning, Mr. Smith." "What is your name, and where were you born?" "What surgery are you having today?"

"What is your name, and where were you born?" The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification however, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I don't like latex balloons."

"heart attack.." - Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons).

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "These stockings will prevent blood clots." "These stockings help promote blood flow."

"will prevent blood clots" - Antiembolism stockings alone will not prevent deep vein thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). Antiembolism stockings may be used during and after surgery to promote venous return.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test does the nurse expect to help confirm the diagnosis? Bronchoscopy Chest x-ray Computed tomography (CT) scan Thoracoscopy

(CT) scan CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli. The client has a pulmonary embolism; bronchoscopy will not help to confirm this diagnosis. A chest x-ray will rule out other causes of the symptoms but is not specific for pulmonary embolism. Thoracoscopy is not used to detect pulmonary emboli.

The patient states the surgeon discussed the addition of a second procedure to the one indicated on the consent. The patient is visibly upset that the consent he is asked to sign with the surgical resident reflects only one procedure and cannot understand why the nurse and resident do not have the authority to "fix" the consent. In addition, he states he will not take his wedding ring off because it has never left his hand since his wife put it there 30 years ago. 1. How would you address the patient's immediate concern regarding the consent? 2. Under what conditions could the second procedure be performed? 3. What remedy would you propose to prevent such occurrences in the future? 4. How will you respond to the patient's unwillingness to remove his wedding ring?

1. How would you address the patient's immediate concern regarding the consent? Focus your answer on the safety aspect of the situation while acknowledging the patient's frustration. Inform the patient that you will contact the surgeon to clarify the consent in terms of accuracy and that neither you nor the surgical resident not have the authority to alter the consent without the surgeon's knowledge. Document it in the medical record. 2. Under what conditions could the second procedure be performed? The second procedure could be performed if a new consent is developed with both procedures listed and signed by the patient. This new consent can only be used if the patient is not under the influence of preoperative drugs that could cloud his judgment and if the patient has received adequate information regarding both procedures to be able to make an informed choice. 3. What remedy would you propose to prevent such occurrences in the future? Discuss the occurrence with the perioperative team, review existing policy, and make changes as needed. Propose a process for facilitating communication among departments and team members. 4. How will you respond to the patient's unwillingness to remove his wedding ring? Explain to him that removal of the ring is not necessary if the finger is not the operative site. Tape the ring in place if agency policy permits. If the agency does not permit this action, explain why and have his wife keep the ring with her until she sees him after surgery.

A patient scheduled for a palliative, pain-relieving procedure has a do-not-resuscitate (DNR) order confirmed in the medical record. However, after being premedicated, the patient requests the order be suspended during the procedure and that a family member be contacted. 1. Is the patient permitted to suspend the DNR order in light of the fact that he has already received premedication? 2. What principle of ethical behavior guides your response? 3. How should the OR nurse proceed with the patient request? 4. What steps could be taken to ensure that patient requests and revisions of requests can be handled appropriately in the future?

1. Is the patient permitted to suspend the DNR order in light of the fact that he has already received premedication? This is a tricky situation. The hospital, surgeon, and other members of the health care team do not have the authority to suspend arbitrarily the DNR order during the perioperative period. However, the patient should be able to change his or her mind and request that the DNR order be suspended temporarily. Because the patient has already received premedication, his or her request needs to be evaluated on the basis of his or her ability to understand and make good decisions. It is possible that the preoperative drugs administered did not contain any drugs that alter cognition. It would be good to ask the patient what his or her concerns are about the DNR order during the perioperative period. Then any misinformation or unrealistic concerns could be clarified. Bringing in a family member at the patient's request is reasonable, especially if this person has medical power of attorney. All in all, the patient does have the right to suspend the DNR order. 2. What principle of ethical behavior guides your response? The important principles guiding the outcome are beneficence, nonmaleficence, and autonomy. Beneficence requires that the nurse do good for the patient. Thus, helping the patient emotionally by honoring his or her request to suspend the DNR would meet this principle. Nonmaleficence stresses the importance that the patient not be harmed. Suspending the DNR would not physically or emotionally harm this patient. Autonomy is the patient's right to self-determination. If it can be judged that the patient is cognitively aware sufficiently to know the consequences of suspending the DNR temporarily, the principle of autonomy would not be violated. 3. How should the OR nurse proceed with the patient request? Clarify with the patient why he or she wants the suspension. Bring in the family member, the surgeon, and possibly the hospital ethicist and clergy. 4. What steps could be taken to ensure that patient requests and revisions of requests can be handled appropriately in the future? Work with perioperative personnel to establish a policy regarding DNR status changes during the perioperative period. Some of the procedures could include: • Checking to determine which patients have a DNR on the chart before any medications are given • Asking the patient to explain in his or her own words what he or she believes a DNR order means for events that occur surgery • Asking the patient whether he or she wants to maintain or suspend the DNR during the perioperative period • Establishing who, in addition to the patient, should be involved in changing a DNR status • Have the patient voice any concerns or fears regarding the procedure and outcome

Which client is at increased risk for fluid and electrolyte imbalance? (Select all that apply.) A 22-year-old pregnant woman in her third trimester A 24-year-old male athlete A 65-year-old man on diuretics A 47-year-old man traveling to South America in summer A 76-year-old bedridden woman

24, 65, 76 An athlete is at risk for dehydration. An older man on diuretics is at risk for fluid and electrolyte imbalances owing to the action(s) of the drugs. Many of the high-ceiling (loop) diuretics cause loss of potassium as they enable the body to rid itself of excess fluids. Older adults have decreased thirst mechanisms and are at risk for dehydration and subsequent fluid and electrolyte problems. A middle-aged man who is traveling to a hot climate and/or high altitude is at risk for insensible water loss as he acclimates to warmer temperatures. A pregnant client in the third trimester does have an increase in total body fluids, but this accumulation occurs gradually throughout the pregnancy.

A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective? 7.6 mEq/L 5.6 mEq/L 4.6 mEq/L 2.6 mEq/L

4.6 mEq/L A potassium level of 4.6 mEq/L is a normal level, indicating that therapy was effective. Normal levels are 3.5 to 5.0 mEq/L. A potassium level of 7.6 mEq/L indicates severe hyperkalemia. A potassium level of 5.6 mEq/L indicates hyperkalemia. A potassium level of 2.6 mEq/L indicates hypokalemia.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

43-year-old New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. A temperature of 100.4° F and pain upon coughing following bladder surgery are normal on the first postsurgical day. The client awaiting discharge teaching is not a priority.

After receiving change-of-shift report, which client does the RN assess first? A 26-year-old with nausea and vomiting who complains of dizziness when standing A 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mm Hg A 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

46-year-old The client with the history of receiving IV diuretics and having low blood pressure may be experiencing hypoperfusion caused by hypovolemia, and immediate assessment and interventions are needed. The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems that are not urgent at this time.

Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl A 47-year-old obese man with diabetes A 48-year-old woman who smokes A 98-year-old healthy man

47-year-old Diabetes and obesity significantly contribute to slow wound healing. The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure (CHF), and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and oral potassium supplements. He tells the nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The health care provider requests laboratory specimens to be drawn and an isotonic IV to be started. Which IV fluid does the nurse administer? 0.45% saline 5% dextrose in 0.45% saline 5% dextrose in Ringer's lactate 5% dextrose in water (D5W)

5% dextrose in water (D5W) 5% dextrose in water (D5W) is an isotonic solution. 0.45% saline is a hypotonic solution, while 5% dextrose in 0.45% saline and 5% dextrose in Ringer's lactate are hypertonic solutions.

Which client is at greatest risk for hypernatremia? A 17-year-old with a serum blood glucose of 189 mg/dL A 30-year-old on a low-salt diet A 42-year-old receiving hypotonic fluids A 54-year-old who is sweating profusely

54-year-old Excessive sweating is a common cause of hypernatremia. Hyperglycemia, a low-salt diet, and hypotonic fluid administration are common causes of hyponatremia, not hypernatremia.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

6 breaths/min The most important postoperative assessment is respiratory assessment, and a rate of 6 breaths/min is too low. A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is assigned to the LPN/LVN? A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

76-year-old Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates that fluid balance is normal this client is the most stable of the four clients described and can be assigned to the LPN/LVN. The data about the 44-year-old with CHF who has gained 3 pounds since the previous day indicate reduced stability assessments and interventions performed by an RN are needed. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L indicate reduced stability assessments and interventions performed by an RN are needed. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, and that assessments and interventions by an RN are needed.

An 81-year-old client, scheduled for a long orthopedic procedure, appears to have a low body mass index. In addition to the body mass index value, which additional client information is most important for the nurse to report to the surgeon and perioperative team as indicating an increased risk for skin breakdown? A Negative nitrogen balance B Previous abdominal surgery C Allergy to latex products D Change in mental status upon admission

A - A negative nitrogen balance can be a sign of inadequate protein intake and malnutrition, resulting in a low BMI. These factors contribute to skin breakdown. Although the change in mental status can increase the risk for skin breakdown after surgery if the client is not aware of the need to change position, it is not the most critical risk factor at this time. The allergy to latex products is critical information to communicate to the perioperative team but does not contribute to skin breakdown.

The nurse manager of the medical-surgical unit assigns which client to the LPN/LVN? A 44-year-old admitted with dehydration who has a heart rate of 126 beats/min A 54-year-old just admitted with hyperkalemia who takes a potassium-sparing diuretic at home A 64-year-old admitted yesterday with heart failure who still has dependent pedal edema A 74-year-old who has just been admitted with severe nausea, vomiting, and diarrhea

A 64-year-old admitted yesterday with heart failure who still has dependent pedal edema Because the client with heart failure is the most stable of the four clients, this client is most appropriate to assign to the LPN/LVN. Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable and should be cared for by RN staff members.

A 68-year-old man is admitted to the hospital with dehydration. He has a history of atrial fibrillation, congestive heart failure, and hypertension. His current medications are digoxin (Lanoxin), chlorothiazide (Diuril), and potassium supplements. He tells a nurse that he has had flulike symptoms for the past week and has been unable to drink for the past 48 hours. The nurse starts the client's IV and receives laboratory results, which include a potassium level of 2.7 mEq/L. The physician orders an IV potassium supplement. How does the nurse administer this medication? Added to an IV, not to exceed 20 mEq/hr Added to an IV, not to exceed 30 mEq/hr Rapid IV push, a 25-mEq dose Slow IV push, a 30-mEq dose

Added to an IV, not to exceed 20 mEq/hr The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr under any circumstances. Potassium should never be administered via IV push.

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Administer 2 g of cephalothin (Keflin) IV now. Give morphine sulfate 4 to 6 mg IV for pain. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important. Although antibiotic therapy may be ordered, this is not a priority at this time. Pain management in the postoperative period is important; a minimally invasive technique will be less painful than an open technique, but is still painful. Pain management is not the first priority, however. PRBCs may or may not need to be infused to maintain the oxygen-carrying capacity of the blood. Less blood is lost during minimally invasive techniques than during open surgical procedures.

A client who had an earlier bronchoscopy has the following vital signs: heart rate 132 beats/min, respiratory rate 26 breaths/min, and blood pressure 98/50 mm Hg. The client is anxious and his skin is cyanotic. What is the nurse's first action? Call the Rapid Response Team. Give methylene blue 1% 1 to 2 mg/kg by IV injection. Administer oxygen. Notify the health care provider immediately.

Administer oxygen Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety. The Rapid Response Team should be called if the client has any symptoms of methemoglobinemia; calling a rapid response will not be the nurse's first action because abnormal vital signs can result from many causes. Methylene blue is given for treatment of methemoglobinemia; information is insufficient for the nurse to determine whether the client has this condition. The health care provider will receive an update of the client's condition; however, this is not the highest priority at this time.

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? Adventitious breath sounds Fremitus Oxygenation status Respiratory excursion

Adventitious breath sounds Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung. Fremitus is vibration and is not detected by auscultation. Oxygenation status cannot be detected specifically by auscultation. Respiratory excursion is detected by both observation of the movement of the chest and palpation as the client inhales and exhales.

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? Albuterol (Proventil) 2 inhalations Fluticasone (Flovent) 2 inhalations Ipratropium (Atrovent) 2 inhalations Salmeterol (Serevent) 2 inhalations

Albuterol Albuterol is a beta2 agonist that acts rapidly as a bronchodilator. Fluticasone is a corticosteroid; it is used to prevent asthma attacks and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation; it is not as effective as a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time; this client needs a rescue medication.

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (Select all that apply.) Combination drug therapy is effective in preventing transmission. Correct Combination drug therapy is the most effective method of treating TB. Correct Combination drug therapy will decrease the length of required treatment to 2 months. Multiple drug regimens destroy organisms as quickly as possible. Correct The use of multiple drugs reduces the emergence of drug-resistant organisms. Correct

All but 2 months Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

Which situation can cause a client to experience "insensible water loss"? (Select all that apply.) Diarrhea Dry, hot weather Fever Increased respiratory rate Nausea Mechanical ventilation

All but nausea Insensible water loss occurs through the intestinal tract as diarrhea. It can be caused and/or influenced by dry, hot weather. Insensible water loss occurs through the skin, and it is increased by the presence of fever. It occurs through the lungs (increased rate of respirations), and is increased in clients who are mechanically ventilated. Nausea with no accompanying vomiting would not cause insensible water loss.

Where does gas exchange occur? Acinus Alveolus Bronchus Carina

Alveolus The alveolus is the structural unit of the lung where gas exchange occurs. The acinus is a structural unit that includes a bronchiole, an alveolar duct, and an alveolar sac. The bronchus (plural, bronchi) is similar in structure to the trachea, which allows passage of air into the lungs. The carina is the junction where the trachea branches into the left and right bronchi.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? Arrange for a health care worker to watch the client take the medication. Give the client written instructions about how to take prescribed medications. Have the client repeat medication names and side effects. Instruct the client about the possible consequences of nonadherence.

Arrange for a health care worker to watch the client take the medication Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. Also, the question does not indicate whether the client can read. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless may be more concerned with obtaining shelter and food than with properly taking his or her medication.

As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do? Calls the surgeon Calls the anesthesiologist Gives the medication as ordered Asks the client to sign the consent form

Asks the client to sign the consent form The nurse may ask the client to sign the consent form, after which the medication can be administered. Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? Assess the airway, breathing, and circulation. Call for the Rapid Response Team. Check the patency of the chest tubes. Listen for breath sounds.

Assess the airway, breathing, and circulation Assessing the "ABCs" is the priority to determine possible causes of burning in the client's chest. The client's situation does not require the Rapid Response Team to be called. The client's symptoms are not caused by a blockage of chest tubes. Listening for breath sounds would be an appropriate action for the nurse to take to evaluate the client's reported symptoms; however, this would not be the nurse's first action.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? Avoid Cystic Fibrosis Foundation-sponsored events. Avoid the hospital. Stay at home most of the time. Use an antiseptic hand gel.

Avoid Cystic Fibrosis Foundation-sponsored events A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events. Avoiding the hospital completely is unrealistic, although special infection control procedures may be implemented, such as scheduling the client's office visits on different days or in different areas of the hospital. Social isolation is not needed for clients with CF and may be detrimental to the psychosocial well-being of the client. Hand hygiene is important, although this is not the best response.

People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilation? (Select all that apply.) Bakers Coal miners Electricians Furniture refinishers Plumbers Potters

Bakers, Coal Miners, Furniture refinishers, Potters Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk to develop pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters. Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? Barrel chest Cough Dyspnea Reduced gas exchange

Barrel chest Interstitial lung diseases are restrictive, not obstructive, so they do not cause barrel chest, which is the result of air trapping. Both types of pulmonary disease cause cough, dyspnea, and reduced gas exchange.

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Level of consciousness Oxygen saturation Surgical site

Breathing pattern Respiratory assessment is the most important. Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.

Which assessment finding is of greatest concern in a client with emphysema? Barrel-shaped chest Bronchial breath sounds heard at the bases Hyperresonance to percussion of the chest Ribs lying horizontal

Bronchial breath sounds heard at the bases Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia. The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so he will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the lungs in a client with emphysema to lie in a horizontal direction.

Which component of a client's family history is of particular importance to the home health nurse who is assessing a new client with asthma? Brother is allergic to peanuts. Father is obese. Mother is diabetic. Sister is pregnant.

Brother is allergic to peanuts Clients with asthma often have a family history of allergies; it will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack. Obesity, diabetes, and pregnancy are not correlated with asthma.

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? By nasal cannula at a rate of no more than 1 to 3 L/min By nasal cannula at a rate of no more than 2 to 4 L/min By Venturi mask at a rate of at least 60% By maintaining oxygen saturations greater than 88%

By maintaining oxygen saturations greater than 88% In the past, a client with COPD was thought to be at risk for extreme hypoventilation with oxygen therapy because of a decreased drive to breathe as blood oxygen levels increased. However, recent evidence does not support this; this idea has been responsible for ineffective management of hypoxia in clients with COPD. All hypoxic clients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92%

The preoperative admitting nurse notices that the client scheduled for total joint replacement surgery in 2 hours has a smell of alcohol on his breath even though he has just stated that he has fasted completely for the past 10 hours. What is the nurse's best first action? A Accept the client's statement and continue the preoperative preparation. B Report the discrepancy to the surgeon and anesthesiologist immediately. C Tell the client the observation and provide the opportunity for him to explain. D Remind the client that alcohol consumption may require changes in anesthesia procedure.

C - Although alcohol consumption before a surgical procedure with anesthesia can cause serious problems, the nurse should not "jump to conclusions" with his or her observations. Before informing the surgeon and anesthesiologist, the nurse should provide the client with the opportunity to explain the alcohol smell on his breath. Some mouthwashes contain chemicals and alcohol that could leave a perceptible odor. Also, the nurse could be mistaken about the odor.

Which change in the anesthetized client alerts the nurse to the possibility of malignant hyperthermia? A. Widening pulse pressure B. Increasing output of dilute urine C. Increasing end-tidal carbon dioxide level D. Ascending flaccid paralysis of skeletal muscles

C - The carbon dioxide level of expired (exhaled) air is an indication of acid-base balance. With malignant hyperthermia, the metabolism of skeletal muscles is greatly increased, generating extreme heat and causing an oxygen debt. This condition leads to lactic acidosis and increased production of carbon dioxide. A rise in end-tidal carbon dioxide level is the most sensitive indicator of the presence of malignant hyperthermia. A common mistake is to assume the best indication of malignant hyperthermia is a dramatic rise in body temperature. This is a very late sign, and if interventions are delayed until then, the risk for death or significant brain damage is increased.

Because of an unexpected emergency case, a client scheduled for colon surgery at 8 am has been rescheduled for 11 am. What is the nurse's best action related to preoperative prophylactic antibiotic administration according to the Surgical Care Improvement Project (SCIP) guidelines? A Administer the preoperative antibiotic at 7 am as originally prescribed. B Administer the antibiotic at the same time as the other prescribed preoperative drugs. C Adjust the antibiotic administration time to be within 1 hour before the surgical incision. D Hold the preoperative antibiotic until the client is actually in the operating room and has been anesthetized.

C - The goal of prophylaxis is to establish bactericidal tissue and serum levels at the time of skin incision. The SCIP recommendations are that the antibiotic be administered 1 hour before the actual surgical incision. Giving the drug at 7 AM seriously interferes with maintaining the blood (serum) level at the proper level when the surgery is actually taking place. Administering the antibiotic with the other preoperative drugs may or may not be within the recommended time frame. Waiting until the client is anesthetized is too late for best antibiotic action and peak serum levels.

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? Calcium level of 9.5 mg/dL Magnesium level of 4.1 mEq/L Potassium level of 6.0 mEq/L Sodium level of 120 mEq/L

Calcium level of 9.5 mg/dL Because a calcium level of 9.5 mg/dL is within normal limits, it is appropriate to assign this client to an LPN/LVN. A magnesium level of 4.1 mEq/L, potassium level of 6.0 mEq/L, and a sodium level of 120 mEq/L are abnormalities in electrolytes that can cause serious complications and will require assessments and/or interventions by the RN.

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? Calmly continues talking Checks the tube for blocks or kinks Immediately calls the health care provider Strips the chest tube

Calmly continues talking Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. Any bubbling that is occurring would stop if a kink or a blockage is present in the chest tube. The chest tube is functioning normally; there is no need to notify the health care provider. "Stripping the chest tube" greatly increases pressure inside the chest and could potentially damage lung tissue; any excessive manipulation should be avoided.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? Check the resident's oxygen saturation. Do a complete neurologic assessment. Give the prescribed PRN lorazepam (Ativan). Notify the resident's primary care provider.

Check the resident's oxygen saturation A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation; this will take several minutes to complete. Administering lorazepam may make the client more confused and agitated because antianxiety drugs may cause a paradoxical reaction, or opposite effect, in some older clients. Depending on the results of the client's pulse oximetry and neurologic examination, notifying the primary care provider may be an appropriate next step.

A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? Actively listen to this client's concerns. Allow the client to wear the hearing aid to surgery. Check to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given. Apologize to the client and explain that it is hospital policy to remove a hearing aid before surgery.

Check to see In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction. The OR staff may have a different policy, considering that the hearing aid may get lost. Listening isn't always enough more intervention is needed. Telling the client that a policy precludes the client's needs is not therapeutic.

What is the greatest risk factor for lung cancer? Alcohol consumption Asbestos exposure Cigarette smoking Smoking marijuana

Cigarette smoking Cigarette smoking is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease. Alcohol can cause some cancers and liver disease and can increase risky behaviors, but it is not a major cause of lung cancer. Although asbestos is carcinogenic and some components of marijuana are carcinogenic, neither is the major risk factor for lung cancer.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours Ceftriaxone (Rocephin) 2 g IV every 8 hours Ciprofloxacin (Cipro) 400 mg IV every 12 hours Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day

Ciprofloxacin Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis. Oral doses of amoxicillin are used only as prophylaxis, not as treatment, for inhaled anthrax. Cephalosporins such as ceftriaxone are not used for treatment of anthrax. Pyrazinamide (Zinamide) is used for treatment of tuberculosis.

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? Surgical technologist with 10 years of experience in the OR at this hospital Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals Holding room RN who has worked in the hospital holding room for longer than 15 years Circulating RN who has been employed in the hospital OR for 7 years

Circulating RN The circulating RN has the experience and background to write OR policy and has been employed in this hospital and is aware of hospital policy and procedures. A surgical technologist does not have the background to write policy for nurses. A CRNFA has worked in multiple hospitals but does not have a work history with this specific hospital to be aware of the unit policy. A holding room or preoperative or postoperative care nurse would not be the choice to write OR policy

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? Circulating nurse Holding nurse Anesthesiologist Surgeon

Circulating nurse All OR team members are responsible, but the circulating nurse moves around the room and can see more of what is happening. The holding nurse is not in the operating room. The anesthesiologist is focused on providing sedation to the client. The surgeon is concentrating on the surgery and usually cannot monitor all staff.

Who is the most likely person to administer blood products in an operating suite? Circulating nurse Holding area nurse Scrub nurse Specialty nurse

Circulating nurse Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Holding area nurses manage the client's care before surgery blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Specialty nurses may be in charge of a particular type of surgical specialty they are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? Class I, can perform manual labor Class II, can perform desk job Class III, minimally employable Class IV, must remain at home

Class II, can perform desk job This client is dyspneic when climbing stairs or walking on an incline, but not on level walking; therefore, this client is considered class II and employable only for a sedentary job or under special circumstances. If the client had class I dyspnea, the dyspnea would only occur on more-than-normal or strenuous exertion; this client's dyspnea occurs beyond normal or strenuous exertion, so he or she would not be able to perform manual labor. The client's dyspnea does not occur on minimal exertion (class III), and does not prevent him or her from performing essential activities of daily living (class IV), so the client is still employable in some capacity.

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? Client behavior that changes from anxious and restless to lethargic and confused Deep furrows on the surface of the tongue Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched Urine output of 950 mL for the past 24 hours

Client behavior that changes from anxious and restless to lethargic and confused The client's change in level of consciousness from anxious and restless to lethargic and confused suggests poor cerebral blood flow, or shrinkage or swelling of brain cells caused by fluid shifts within the brain cells. These changes indicate a need for immediate intervention to prevent further damage to cerebral function. Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

The nurse is working in an urgent care clinic. Which client needs to be evaluated first by the nurse? Client who is short of breath after walking up two flights of stairs Client with soreness of the arm after receiving purified protein derivative (Mantoux) skin test Client with sore throat and fever of 102.2° F (39° C) oral Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry

Client who is speaking in three-word sentences and has an SpO2 of 90% by pulse oximetry A client should be able to speak in sentences of more than three words, and an SpO2 of 90% indicates hypoxemia that requires intervention on the part of the nurse. Shortness of breath after walking up two flights of stairs may not be an emergency. Although not a usual finding, the arm may be sore after a skin test is performed. Sore throat and fever are symptoms of infection that require further evaluation but not emergently.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? Client with acute allergic reaction Client with dyspnea on exertion Client with lung cancer with cough Client with sinus infection and fever

Client with acute allergic reaction An acute allergic reaction can lead to immediate respiratory distress; this is an emergent situation that requires the immediate attention of the nurse. Dyspnea on exertion is a condition that will need further evaluation by the nurse, but is not usually an emergency. Coughing is a frequent symptom of lung cancer; although coughing may be related to something not associated with the client's cancer, this situation is not an emergency. Sinus infections are not considered emergencies.

The RN has received report about all of these clients. Which client needs the most immediate assessment? Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago Client with pleural effusion who has decreased breath sounds at the right base

Client with acute asthma An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation. The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed, if this was not already completed. The client who had a bronchoscopy 3 hours ago and has returned to the floor does not require the most immediate attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. Client with emphysema who requires instruction about correct use of oxygen at home. Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day.

Client with acute asthma episode Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis. Although chronic pleural effusions can occur in the pediatric population, this diagnosis is more common in the adult population. If this client has not already received teaching for this procedure, he or she may have questions that the pediatric nurse would not be as comfortable answering as a nurse who is regularly assigned to the stepdown unit. Emphysema is a diagnosis associated with an adult population; although an RN could instruct a client about home oxygen therapy, this client might have questions that would be better answered by an RN with adult experience. The adult client who has just had a lobectomy needs careful assessment from an RN with adult stepdown unit experience.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. Client with lung cancer who needs an IV antibiotic administered before going to surgery.

Client with cystic fibrosis The client with CF with an elevated temperature and respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first. The nurse will need to speak with the client who has COPD to help find a plan that will enable the client to obtain his or her prescribed medications; this may involve contacting case management or social services and discussing the discharge with the discharge health care provider. An oxygen saturation of 89% may be normal for a hospice client with terminal pulmonary fibrosis; not enough information is provided to determine whether this client is in distress. The client who needs an IV antibiotic could have the medication administered by another RN, or it could be administered in the operating room.

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client would be best to reschedule? Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

Client with emphysema The client with emphysema has an appropriate SpO2 for home oxygen use. A positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs follow-up and reporting, because this becomes a public and a personal health issue. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that he has adequate respiratory function to meet his basic oxygenation needs. Although a percutaneous lung biopsy may be an outpatient procedure, pneumothorax or hemothorax is a possible life-threatening complication of this procedure that would cause dyspnea and requires assessment in a timely manner by the home health nurse.

Which client does the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? Client with allergic rhinitis scheduled for skin testing Client with emphysema who needs teaching about pulmonary function testing Client with pancreatitis who needs a preoperative chest x-ray Client with pleural effusion who has had 1200 mL removed by thoracentesis

Client with pleural effusion who has had 1200 mL removed by thoracentesis A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis. Skin testing is performed in the outpatient setting. Pulmonary function testing is not a procedure that requires PACU care. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? Client with bacterial pneumonia and a cough productive of green sputum Client with neutropenia and pneumonia caused by Candida albicans Client with possible pulmonary tuberculosis who currently has hemoptysis Client with right empyema who has a chest tube and a fever of 103.2° F

Client with possible pulmonary tuberculosis who currently has hemoptysis A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? Client with group A beta-hemolytic streptococcal pharyngitis who has stridor Client with pulmonary tuberculosis who is receiving multiple medications Client with sinusitis who has just arrived after having endoscopic sinus surgery Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN.

A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath, and 3+ pitting edema in her lower extremities. Her medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Ten hours after receiving the Lasix, the client's potassium (K+) level is 2.5 mEq/L. Knowing all of the client's medications, what problem does the nurse anticipate in this client? Clinical manifestations of digoxin toxicity Increased heart rate and blood pressure (BP) Increased signs of congestive heart failure (CHF) Signs and symptoms of hypernatremia

Clinical manifestations of digoxin toxicity Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. Heart rate and BP would be more likely to decrease with the medications that the client is receiving coupled with her low potassium level. Use of a diuretic tends to decrease the signs of CHF. High serum sodium levels would not be expected in this scenario.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form.

Contact the surgeon - The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? Completing the antibiotic medication regimen Taking pain medications every 4 to 6 hours Contacting the provider if the throat feels more swollen Using warm saline gargles and irrigations

Contacting the provider if the throat feels more swollen Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. It is important to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but none of these is the most important thing to teach the client.

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

Cover the wound Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? Crackles Rhonchi Pleural friction rub Wheeze

Crackles Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload. Rhonchi are low-pitched, coarse snoring sounds caused by fluid or secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky; they may occur on inspiration or on expiration and may be heard without a stethoscope as air rushes through narrowed airways.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL Fasting glucose, 80 mg/dL Potassium, 3.9 mEq/L Sodium, 140 mEq/L

Creatinine - A creatinine of 1.9 mg/dL is outside the normal range and may indicate renal problems. A fasting glucose of 80 mg/dL, a potassium level of 3.9 mEq/L, and sodium level of 140 mEq/L are normal laboratory values

While at the scrub sink, the scrub person informs the circulating nurse that she now wears artificial nails because her own nails break frequently posing a risk for a glove puncture. What is the nurse's best response? A. Ask the scrub person to wear double-gloves to prevent puncture or contamination. B. Confirm with the scrub person that artificial nails are acceptable and do not affect hand hygiene. C. Support the scrub person's rationale that broken nails are a serious source of cross-contamination. D. Remind the scrub person that artificial nails alter skin flora, impede hand hygiene, and are not permitted.

D - Although a punctured glove can cause contamination, artificial nails have been proven to harbor many pathogenic organisms even after the person has correctly performed an appropriate scrub. The World Health Organization's Guidelines on Hand Hygiene in Health Care warn against their presence in scrubbed operating room (OR) personnel.

As adults age, which common physiologic change is likely to alter their hydration status? Adrenal gland growth Decreased muscle mass Increased thirst mechanism Poor skin turgor

Decreased muscle mass Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Adrenal growth is not a common age-related change. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status.

What will withdrawal of alcohol before surgery lead to?

Delirium Tremens

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which actions would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.

Develop the discharge teaching plan Education and preparation for discharge are within the scope of practice of the RN. Reinforcing the need to cough and deep-breathe, and monitoring the client are within the scope of the LPN/LVN nurse. LPN/LVNs can also administer pain medications.

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds over the client's ideal body weight

Diet-controller DM - Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese.

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? Decreased sensation in the lower extremities Diminished peripheral pulses in the lower extremities Pale, cool extremities Reddened areas over bony prominences

Diminished peripheral pulses in the lower extremities iminished peripheral pulses in the lower extremities indicate diminished blood flow. Decreased sensation pale, cool extremities and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? Administer levofloxacin (Levaquin) 500 mg IV. Draw aerobic and anaerobic blood cultures. Give lorazepam (Ativan) as needed for agitation. Refer to social worker for alcohol counseling.

Draw aerobic and anaerobic blood cultures Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action; the question indicates that the client is agitated but does not indicate whether other attempts to control agitation have been tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge; this client is febrile and agitated, and a referral is not the immediate concern.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

Draw blood - If blood work is abnormal, the surgery may be rescheduled. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.

Which method is the best way to prevent outbreaks of pandemic influenza? Avoiding public gatherings at all times Early recognition and quarantine Vaccinating everyone with pneumonia vaccine Widespread distribution of antiviral drugs

Early recognition and quarantine The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings should be avoided only if a widespread outbreak has occurred in a community. No vaccine is available for pandemic influenza. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? Draws blood for laboratory tests Elevates the head of the bed Places the extremities in a dependent position Puts the client in a side-lying position

Elevates the head of the bed Elevating the head of the bed will ease breathing for the client, so it should be done first. Although drawing blood for laboratory tests may be indicated, the nurse should perform interventions that will help with physiologic changes caused by fluid overload first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-lying position increases the work of breathing.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How does the nurse assist the client initially with the anxiety associated with the new diagnosis? Encourage the client to ask questions and verbalize concerns. Leave the client alone to deal with his or her own feelings. Medicate the client with diazepam (Valium) for anxiety every 8 hours. Provide journals about cancer treatment.

Encourage the client to ask questions and verbalize concerns. Anxiety causes increased oxygen consumption, and oxygen availability is limited in lung cancer; the availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety. The client may choose to be alone, although this may be a maladaptive coping behavior. Scheduled medication does not solve the anxiety associated with the new diagnosis, although administering Valium (diazepam) every 8 hours will assist with reducing the anxiety; it is more important to work with the client to determine the cause of the anxiety and assist him or her in dealing with those issues first. Knowledge about cancer may help relieve anxiety but is not the best initial step in a newly diagnosed client. The nurse must first assess how the client learns best and what the client's needs are. The nurse also must be aware of the plan of care for the client.

In assessing the client's respiratory status, arterial blood gas (ABG) test results reveal pH of 7.50, PaO2 of 99 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 22 mEq/L. What action does the nurse need to take first? Call the health care provider. Encourage the client to slow his breathing rate. Nothing; these results are within the normal range. Provide oxygen support.

Encourage the client to slow his breathing rate The ABGs indicate respiratory alkalosis, which is commonly caused by hyperventilation; encouraging the client to slow down his breathing rate may help the client return to normal breathing and may correct this abnormality. This situation is not an emergency condition and does not require that the health care provider be called or that oxygen be given. The client's PaO2 is within normal limits, but it is important for the nurse to assess the client and not just look at the numbers.

Which nursing intervention is the priority in preparing a client for pulmonary function testing (PFT)? Administer bronchodilator medication on call. Encourage clear fluid intake 12 hours before the procedure. Ensure no smoking 6 hours before the test. Provide supplemental oxygen as testing begins.

Ensure no smoking 6 hours before the test If the client has been smoking, this may alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results. Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Fluid intake does not have an effect on PFT testing. Unless the client develops distress during testing, supplemental oxygen is not required and will alter the results of PFT.

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? Tell the client that she will be asleep. Ensure that drapes will minimize perianal exposure. Explain postoperative expectations. Restrict the number of technicians in the procedure.

Ensure that drapes will minimize perianal exposure Using drapes is the best action to take. Telling the client that she will be asleep or explaining the procedure will not alleviate the client's anxiety. The number of people involved in the procedure is not something the nurse can necessarily control.

What does the nurse do first when setting up a safe environment for the new client on oxygen? Ensures that staff members wear protective clothing Ensures that no combustion hazards are present in the room Sets the oxygen delivery to maintain no fewer than 16 breaths/min Uses a pulse oximetry unit

Ensures that no combustion hazards are present Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use. Protective clothing is not necessary for a client who requires oxygen therapy other than the use of Standard Precautions. The oxygen delivery setting is usually determined in conjunction with the respiratory therapy care partner. Although the setting is important for safe administration, it is not necessary for a safe environment. Pulse oximetry would be useful for monitoring the client's oxygenation status, but is not necessary for a safe environment.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? Ethambutol Isoniazid Incorrect Pyrazinamide Rifampin

Ethambutol Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless. Contact lenses will also be stained and oral contraceptives will be less effective.

The nurse is teaching a client who is taking a potassium-sparing diuretic about what foods to avoid. Which foods contain high amounts of potassium? (Select all that apply.) Apples Bananas Broccoli Oranges Spinach

Everything but apples Foods high in potassium include bananas, cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Apples are considered to be low in potassium.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? Crackles on auscultation Fever Headache Wheezing

Fever Older adults may not have fever and may have a lower-than-normal temperature with pneumonia. Crackles on auscultation may be present in all age groups as the result of fluid in the lungs. All age ranges may have a headache with pneumonia. Wheezing is an indication of narrowed airways and can be found in all age groups.

What is the term for the opening between the vocal cords? Arytenoid cartilage Epiglottis Glottis Palatine tonsils

Glottis The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery. The arytenoid cartilages work with the thyroid cartilage to control the movement of the vocal cords. The epiglottis is a structure that prevents aspiration during swallowing. The palatine tonsils are part of the immune system and are located in the oropharynx.

The nurse instructs an older adult client to increase intake of dietary potassium when the client is prescribed which classification of drugs? Alpha antagonists Beta blockers Corticosteroids High-ceiling (loop) diuretics

High-ceiling (loop) diuretics High-ceiling (loop) diuretics are potassium-depleting drugs. The client should increase intake of dietary potassium to compensate for this depletion. Alpha antagonists, beta blockers, and corticosteroids are not potassium-depleting drugs.

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action? Call the legal department. Call the client's primary health care provider. Honor the DNR order. Resuscitate per OR procedure.

Honor the DNR order According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination. Calling the legal department or the client's health care provider is not an appropriate response. Resuscitating this client after a DNR has been signed is illegal.

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? Monitoring 24-hour urine output Asking the client about feeling depressed Hourly deep tendon reflexes (DTRs) Monitoring of serum calcium levels

Hourly deep tendon reflexes (DTRs) The client who is receiving IV magnesium sulfate should be assessed for signs of toxicity every hour by assessment of DTRs. Most clients who have fluid and electrolyte problems will be monitored for intake and output this will not immediately generate data about problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not be a method by which to safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? "I am here to receive the yearly pneumonia shot again." "I am here to get my yearly flu shot again." "I should avoid large gatherings during cold and flu season." "I should cough into my upper sleeve instead of my hand."

I am here to receive the yearly pneumonia shot again Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once. Older clients are encouraged to receive a flu shot annually because the vaccine changes, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. New recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? "I don't need to use my oxygen all the time." "I don't need to get a flu shot." "I need to eat more protein." "It is normal to feel more tired than I used to."

I don't need to get a flu shot An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered, since pneumonia is one of the most common complications of COPD. The client who is hypoxemic and also has chronic hypercarbia requires lower levels of oxygen delivery, and may not need it all the time. Increased work of breathing in a client with COPD raises calorie and protein needs, which can lead to protein-calorie malnutrition. Clients with COPD often have chronic fatigue.

The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? "I may need to restrict my activities for several months." "The dressing should stay in place unless it gets wet." "The incision needs to be cleaned every 4 hours with hydrogen peroxide." "The wound will completely heal in about 2 months."

I may need to restrict my activities To protect the integrity of the wound, activities may need to be restricted. The wound will need to be open to air for healing. Using hydrogen peroxide can cause wound irritation, unless specifically ordered. The length of time it takes for a wound to heal varies a wound can take up to 2 years to heal.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? "Asthma drugs help everybody breathe better." "I must carry my emergency inhaler only when activity is anticipated." "I must have my emergency inhaler with me at all times." "Preventive drugs can stop an attack."

I must have my emergency inhaler with me at all times Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol [Proventil]). Asthma medications are specific to the disease and should never be shared or used by anyone other than the person for whom they are prescribed. An emergency inhaler should be carried when activity is anticipated, as well as at other times. Preventive drugs are those that are taken every day to help prevent an attack from occurring. They are not able to stop an attack once it begins.

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? "I don't have to wait between the two puffs if I use a spacer." "If the spacer makes a whistling sound, I am breathing in too rapidly." "I should rinse my mouth and then swallow the water to get all of the medicine." "I should shake the inhaler only if I want to see whether it is empty."

If the spacer makes a whistling sound, I am breathing in too rapidly Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client must wait 1 minute between puffs. The client should rinse the mouth but not swallow the water. The mouth needs to be rinsed after using an inhaler with or without a spacer. This is especially important if the inhaled medication is a corticosteroid, to prevent the development of an oral fungal infection. An empty inhaler will float on its side in water; a full inhaler will sink. Shaking an inhaler helps ensure that the same dose is delivered in each puff.

The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action? Administer cardiopulmonary resuscitation. Continue as normal. Immediately stop all inhalation anesthetic agents and succinylcholine. Inform the surgeon.

Immediately stop all inhalation This client is exhibiting early symptoms of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed, and MH requires immediate intervention. This client does not require resuscitation. Informing the surgeon is not the priority.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? Assess the puncture site for drainage. Implement nothing-by-mouth (NPO) status. Monitor for signs of anaphylaxis. Perform aggressive chest physiotherapy.

Implement nothing-by-mouth (NPO) status Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. No external puncture site is needed for bronchoscopy. Although the client will have received medications during the bronchoscopy, an anaphylactic reaction will occur immediately, not in a client who has returned to the medical unit. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

In the older adult client, which respiratory change requires no further assessment by the nurse? Increased anteroposterior (AP) diameter Increased respiratory rate Shortness of breath Sputum production

Increased anteroposterior (AP) diameter Increased AP diameter is normal with aging. Increased respiratory rate is not a normal finding with aging and may be an indication of pain or infection; it needs to be evaluated further by the nurse. Shortness of breath is not associated with aging and needs to be evaluated further, because it may be related to infection, tumor, or cardiac issues, for example. Sputum production is not related to the aging process; although it may be chronic in nature, it should be assessed further. It is important to note the character and quantity of the sputum, as well as the duration of sputum production.

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? Hair loss Increased risk for sunburn Loss of appetite Pain at site of treatment

Increased risk for sunburn Skin in the path of radiation is more sensitive to sun damage; therefore, clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed. Alopecia, or hair loss, is a side effect of chemotherapy, not of radiation. Loss of appetite is not specific to radiation therapy. Radiation therapy itself is painless and sensation-free; however, the skin may become sore and prone to breakdown over the course of treatment.

A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath, and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working? Decreased blood pressure (BP) Increased heart rate Increased urine output Weight gain

Increased urine output When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the most important assessment to be monitored. Urinary output is most important. Lasix may cause a decrease in heart rate as it lowers the client's body fluid, but this effect would take some time to note. Weight loss, rather than weight gain, is often the effect of Lasix, but it does not occur immediately.

A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? Administers 5 mEq intramuscularly Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr Infuses 10 mEq over a 1-hour period Pushes 5 mEq through a central access line

Infuses 10 mEq over a 1-hour period A dose of KCl 10 mEq given over 1 hour is appropriate for this client. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines.

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy

Insert retention catheter - Insertion of a catheter is within the scope of skills approved for the LPN/LVN. Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure. Laboratory results include a potassium level of 7.0 mEq/L. Which medication does the nurse anticipate administering? Insulin (regular insulin) and dextrose (D20W) Loperamide (Imodium) Sodium polystyrene sulfonate (Kayexalate) Supplemental potassium

Insulin (regular insulin) and dextrose (D20W) If potassium levels are high, a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water may be prescribed to promote movement of potassium from the blood into the intracellular fluid. Imodium is used in the treatment of diarrhea. Kayexalate is used for hyperkalemia, but not when the potassium level is this high (7.0). Additional potassium would make the client's condition more critical.

What pain management does a client who has been admitted to the postanesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics

Intravenous opioid analgesics Intravenous (IV) opioids are given in small doses to provide pain relief, but not to mask an anesthetic reaction. Intramuscular nonopioid analgesics and opioid analgesics are too long-acting. IV nonopioid analgesics usually are not given within the first 48 hours after surgery.

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB. Metronidazole is used to treat anaerobic bacteria and some parasites, but is not effective against TB. Acyclovir is used to treat viral infection. Flunisolide is a corticosteroid that is useful in asthma or other airway disease to prevent wheezing. Prednisone is a steroid. Guaifenesin is a mucolytic. Ketorolac is a nonsteroidal anti-inflammatory drug that is used for short-term pain relief. Salmeterol and cromolyn sodium would most likely be given to clients with respiratory difficulties such as poorly controlled asthma from allergic sources. Dexamethasone is a steroid.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? It would not be beneficial for this client. It would help decrease the bronchospasm. It would clear up the density in the bases of the client's lungs. It would decrease the client's pain on inspiration.

It would help decrease the bronchospasm A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath. A bronchodilator would not be able to clear up the density in the bases of the client's lung. The cause of the density is unknown; however, an infection such as pneumonia is likely, which bronchodilators do not treat. Although a bronchodilator would help a client breathe easier, it does not have any analgesic properties.

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? Assessment of muscle tone and strength Education about potassium-rich foods Instruction on the proper use of drugs Measurement of the client's urine output

Measurement of the client's urine output A home health aide may measure the client's intake and output, which then would be reported to the RN. Assessment, education, and instruction are higher-level nursing actions that should be done by the RN.

A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced nursing assistant working in the PACU? Assess breath sounds. Check gag reflex. Determine level of consciousness. Monitor blood pressure and pulse.

Monitor blood pressure and pulse A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia. Evaluating breath sounds and gag reflex and determining level of consciousness require the skill and knowledge of a higher-level provider.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? Albuterol (Proventil) inhaler Guaifenesin (Organidin) Montelukast (Singulair) Omalizumab (Xolair)

Montelukast Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication. Albuterol inhalers are beta2 agonists that are rescue medications used on an as-needed basis only. Guaifenesin is a mucolytic that does not provide any bronchodilation; it may or may not be taken daily. Omalizumab is an immunomodulator that is injected subcutaneously every 2 to 3 weeks; it is not commonly used because a high rate of anaphylaxis is associated with it.

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? Mucolytics decrease secretion production. Mucolytics increase gas exchange in the lower airways. Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. Mucolytics thin secretions, making them easier to expectorate.

Mucolytics thin secretions The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin, making them easier to expectorate; this is important for a client with chronic bronchitis. Mucolytics do not decrease secretion production. Mucolytics may increase gas exchange, but this is an indirect property and is not the main function. Mucolytics do not have any bronchodilation properties.

The nurse is assessing a client with hyponatremia. Which finding requires immediate action? Diminished bowel sounds Heightened acuity Muscular weakness Urine output of 35 mL/hr

Muscular weakness Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present, immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.

A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? Auscultating bowel sounds Checking deep tendon reflexes (DTRs) Determining the level of consciousness (LOC) Obtaining a pulse oximetry reading

Obtaining a pulse oximetry reading Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client's respiratory status should be assessed first. Bowel sounds, DTRs, and LOC may change in a client with hypokalemia, but these changes are not immediately life-threatening.

The RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? Inserting a small-gauge needle for intravenous (IV) access Evaluating a headache that develops during the transfusion Explaining to the client the purpose of the blood transfusion Obtaining baseline vital signs before blood administration

Obtaining baseline vital signs before blood administration UAP education includes assessment of vital signs, so obtaining vital signs is within their scope of practice. IV starts, evaluating client symptoms, and explaining the purpose of a blood transfusion require broader education and scope of practice and should be done by licensed staff members.

The nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them? "Be careful not to overload them with too many oral fluids." "Offer fluids that they prefer frequently and on a regular schedule." "Restrict their fluids in the evening hours if they are incontinent." "Wake them every 2 hours during the night with a drink."

Offer fluids that they prefer frequently and on a regular schedule Because of the decreased thirst mechanism, older adults can become dehydrated and should be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer. Risk of overhydration, especially with oral fluids, is minimal. Fluids should never be restricted because the client is incontinent this is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids however, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? Assessing oral mucosa for dryness Choosing appropriate oral fluids Monitoring skin turgor for tenting Offering fluids to drink every hour

Offering fluids to drink every hour Encouraging a client to take oral fluids is within the scope of practice for UAP. Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor should be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

Which newly written prescription does the nurse administer first? Intravenous normal saline to a client with a serum sodium of 132 mEq/L Oral calcium supplements to a client with severe osteoporosis Oral phosphorus supplements to a client with acute hypophosphatemia Oral potassium chloride to a client whose serum potassium is 3 mEq/L

Oral potassium chloride to a client whose serum potassium is 3 mEq/L Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to administer potassium supplements to the client with hypokalemia. The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.

An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling? Dry oral mucous membranes Orthostatic blood pressure changes Pulse rate of 72 beats/min and bounding Serum potassium level of 4.0 mEq/L

Orthostatic blood pressure changes Blood pressure decreases when changing positions. The client may not have sufficient blood flow to the brain, causing sensations of light-headedness and dizziness. This problem increases the risk for falling, especially in older adults. Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does not assess for fall risk.

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? Apply elastic stockings to lower extremities. Monitor for excessive blood loss. Pad bony prominences. Secure joints on a board in anatomic positions.

Pad bony prominences Padding bony prominences best minimizes skin breakdown. Elastic stockings assist in increased venous return. Monitoring for blood loss and securing joints do not protect the skin

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? Pain on deep inspiration Pain on palpation Pain radiating to the shoulder Pain that is rubbing in nature

Pain radiating to the shoulder Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse. Pain on inspiration and chest pain that is rubbing in nature are usually pulmonary in origin but do not require immediate attention. Pain on palpation is not usually pulmonary in nature; it may be due to trauma or may be referred from another source, such as the gastrointestinal tract.

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative

Pallative - Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? Helps the surgeon change the gown Picks the gauze up with a pair of sterile gloves Picks the gauze up without touching the surgeon Sprays an antimicrobial on the surgeon's gown

Picks the gauze up without touching the surgeon he surgeon is sterile, but the gauze is now nonsterile and must be removed and counted. A sterile gauze touching a sterile gown does not require a gown change. Sterile gloves are not needed to pick the gauze up. An antimicrobial spray is inappropriate in this situation.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? Blood in the sputum Mucoid sputum Pink, frothy sputum Yellow sputum

Pink, frothy sputum Pink, frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse. Blood in the sputum may occur with chronic bronchitis or lung cancer; because this condition is chronic, the situation does not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not emergent.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.

Place a respiratory mask on the client The concern is that this client has TB. A respiratory mask should be placed on the client immediately. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the client know that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? Ensure that ED staff members receive oseltamivir (Tamiflu). Obtain specimens for the H5 polymerase chain reaction test. Place the client in a negative air pressure room. Start an IV line and administer rehydration therapy.

Place the client in a negative air pressure room If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action. If avian influenza is diagnosed, it is important that those exposed receive oseltamivir or zanamivir (Relenza) within 48 hours of contact with the client. Obtaining specimens will be important to determine whether the client has avian influenza; this test takes approximately 40 minutes to complete. A client with avian flu will become dehydrated because of diarrhea, so starting an IV to administer rehydration fluid is important, but is not the first priority.

The health care provider writes orders for a client who is admitted with a serum potassium level of 6.9 mEq/L. What does the nurse implement first? Administer sodium polystyrene sulfonate (Kayexalate) orally. Ensure that a potassium-restricted diet is ordered. Place the client on a cardiac monitor. Teach the client about foods that are high in potassium.

Place the client on a cardiac monitor Because hyperkalemia can lead to life-threatening bradycardia, the initial action should be to place the client on a cardiac monitor. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

The RN and the LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which action is best accomplished by the RN? Administer the purified protein derivative for tuberculosis testing. Assess vital signs and the puncture site after thoracentesis. Monitor oxygen saturation using pulse oximetry every 4 hours. Plan client and family teaching regarding upcoming pulmonary function testing.

Plan client and family teaching Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure. Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can be included in the vital signs assessment.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? Abscess Pneumonia Pneumothorax Pulmonary embolism

Pneumothorax A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms. Although it is possible that an abscess has formed, this is not the most likely diagnosis because it would not cause a great deal of shortness of breath. It is not likely that pneumonia would develop this rapidly, causing this level of symptoms. Thoracentesis is not a cause of pulmonary emboli.

After gastric surgery, a client arrives in the postanesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? Monitor respiratory rate and airway patency. Irrigate the nasogastric tube with saline. Position the client on the left side. Assess the client's pain level.

Position the client on the left side. Positioning the client on the left side can be delegated to an unlicensed care provider. Airway patency requires the care of a nurse in case of emergency management requirements. Irrigating the nasogastric tube with saline is a nursing skill and care by a nurse would be required. Pain assessment is also within the scope of a nurse.

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Post-cough emesis

Post-cough emesis Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing that children with pertussis exhibit. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

The nurse is reviewing serum electrolytes and blood chemistry for a newly admitted client. Which result causes the greatest concern? Glucose: 97 mg/dL Magnesium: 2.1 mEq/L Potassium: 5.9 mEq/L Sodium: 143 mEq/L

Potassium: 5.9 mEq/L A potassium value of 5.9 mEq/L is high, and the client should be assessed further. A glucose value of 97 mg/dL, a magnesium value of 2.1 mEq/L, and a sodium value of 143 mEq/L are normal values.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? Homeless people Hospital staff Politicians Prison staff and inmates

Prison staff and inmates High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed. Education could be provided in shelters or during outreach activities. Hospital staff are at risk owing to their contact with ill clients and family members; however, they are already aware of how to prevent respiratory infection. Politicians are not at higher risk for respiratory infection than any other group with public exposure.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? Ensures that the client is wearing a mask Tells the visitor that the client cannot receive visitors at this time Provides a particulate air respirator to the visitor Provides a mask to the visitor

Provides a mask to the visitor Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator.

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to unlicensed assistive personnel (UAP)? Consulting with a health care provider about a client's laboratory results Infusing 500 mL of normal saline over 60 minutes Monitoring IV fluid to maintain the drip rate at 75 mL/hr Providing oral care every 1 to 2 hours

Providing oral care every 1 to 2 hours Frequent oral care is an important intervention for a client with fluid volume deficit and is appropriate to delegate to UAP. Consulting with a health care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluid are complex actions and should be accomplished by licensed personnel.

Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR

RN who has 5 years of experience in the delivery room The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client. The RN who usually works on the pediatric unit would not be aware of potential complications and routine assessments for this client. The RN who provides education to diabetic clients in a clinic would be able to provide required care for the client's diabetes but not the postoperative aspect of care. The RN who works as a scrub nurse would not have the knowledge and understanding of routine postoperative care that is needed for this client.

The client is a 69-year-old woman with uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? LPN/LVN who has floated from the hospital's long-term care unit LPN/LVN who frequently administers medications to multiple clients RN who has floated from the intensive care unit RN who usually works as a diabetes educator

RN who has floated from the intensive care unit The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock. The RN who floated from the intensive care unit will have extensive experience caring for clients with hypovolemia. The LPN/LVN who has floated from the long-term care unit or who frequently administers medications to multiple clients will not be as familiar with care for critically ill clients. The LPN/LVN is not qualified to care for a client with these complications. Although the resource on diabetes is helpful, the RN who works as a diabetes educator will not be as familiar with care for critically ill clients.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? Crusting along the incision line Redness and swelling around the incision Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

Redness and swelling Redness and swelling around the incision indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? Decrease expected blood loss during surgery Eliminate any risk of infection Ensure that the bowel is sterile Reduce the number of intestinal bacteria

Reduce number of bacteria - Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? Nothing. This is in the green zone. Provide the rescue drug and reassess. Provide the rescue drug and seek emergency help. Repeat the peak flow test.

Repeat the peak flow test Since the client is newly diagnosed with asthma, this would be an excellent opportunity for the nurse to observe the client using the peak flowmeter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best. The result of 82% is in the green zone, but this is not the best answer for a newly diagnosed client. Rescue drugs should be used only in the yellow zone, between 50% and 80% of the client's personal best. They should not be used in this situation, and the nurse does not need to seek emergency help until readings are in the red zone, or below 50% of the client's personal best.

A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first? Blood pressure Pulse Incorrect Respirations Temperature

Respirations Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness results in shallow respirations. Thus, respiratory status should be assessed first in any client who might have hypokalemia. Blood pressure and pulse will be altered in this client, but they are not the priority assessment. Temperature is not a priority assessment for the client with hypokalemia.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure. Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this client? Decreasing cardiac contractility and slowing the heart rate Elevating serum potassium levels to a safe range Maintaining proper diuresis and urine output Restoring fluid balance by controlling the causes of dehydration

Restoring fluid balance by controlling the causes of dehydration Drug therapy for dehydration is directed at restoring fluid balance and controlling the causes of dehydration. Hyperkalemia (serum potassium level of 7.0) will slow the cardiac rate and cause decreased contractility of the heart. Serum potassium levels are already critically high, so should not be elevated further. Excessive diuretic use is what has caused this client's problems. What she needs now is to have electrolyte balance restored for potassium, that is 3.5 to 5.0 mEq/L.

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? Corticosteroids Long-acting beta agonists Nonsteroidal anti-inflammatory drugs (NSAIDs) Short-acting beta agonists

Short-acting beta agonists Short-acting beta agonist medications have a rapid onset and cause bronchodilation; they would be excellent for marathon running because some types of asthma may be exercise-induced. Corticosteroids disrupt production pathways of inflammatory mediators. Maximum effectiveness requires 48 to 72 hours of continued use; therefore, they are not appropriate as a rescue medication. Long-acting beta agonists do cause bronchodilation, but have a slow onset; they are not used as rescue inhalers. NSAIDs stabilize the membranes of mast cells and prevent release of inflammatory mediators. They have a slow onset of action and are used for prevention of symptoms, not as rescue medication.

How does the nurse position a client with postoperative nausea and vomiting? Flat in bed, with the head in alignment with the body Prone, with the head of the bed flat Side-lying, with the head in a neutral position Supine in bed, with the neck flexed

Side-lying The side-lying position helps reduce this distressing symptom. The flat-in-bed position with the head in alignment is not a neutral position. The prone position with the head of the bed flat is unnatural, as is the supine position with the neck flexed.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Snoring sounds when inhaling Sore throat on swallowing

Snoring sounds when inhaling Snoring sounds when inhaling may indicate respiratory depression. Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? Peak flowmeter readings that are yellow after the third reading Productive cough SpO2 level of 92% after ambulating 50 feet Stable arterial blood gases (ABGs)

SpO2 level of 92% after ambulating 50 feet Maintaining a baseline SpO2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective. A yellow reading means "caution," which indicates narrowing airways. Although a productive cough may be an indication of success, it can also be an indication of infection. ABGs are invasive, costly, and painful and are not the most effective indicator of successful teaching in this situation.

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.

Supplemental pain reduction The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.

Talk to the client - The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? Call admissions. Cancel the surgery. Contact the surgeon. Talk to the operating team.

Talk to the operating team - The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Calling admissions is not the first step; the stamp is correct. Canceling surgery is not done by the floor nurse. This is an administrative issue, and not one for the surgeon.

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client where the smoking lounge is.

Teach the importance of incentive spirometry - Incentive spirometry is good for lung hygiene; it encourages deep breathing. The nurse can suggest quitting or advise about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Directing the client to the smoking lounge is not helpful or therapeutic.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? Encourages proper building ventilation Refers workers to a tobacco cessation program Suggests that workers find another job Teaches workers how to use a mask

Teaches workers how to use a mask Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure. Proper building ventilation often requires work orders, reconstruction, time, and money; this will need to be implemented, but it will not occur quickly. Particulate matter can be emitted from a variety of sources; smoking may be unrelated to the question. Suggesting that workers find another job does not solve the problem of particulate matter in a rapid or safe manner.

A 90-year-old client with hypermagnesemia is seen in the emergency department (ED). The ED nurse prepares the client for admission to which inpatient unit? Dialysis/home care Geriatric/rehabilitation Medical-surgical Telemetry/cardiac stepdown

Telemetry/cardiac stepdown Because hypermagnesemia causes changes in the cardiac rhythm that may result in cardiac arrest, the client should be admitted to the telemetry/cardiac stepdown unit. Dialysis/home care units, geriatric/rehabilitation units, and medical-surgical units typically do not have cardiac monitoring capabilities.

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy The 28-year-old client with a fractured femur who is having an open reduction and internal fixation The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

The 52-year-old The client with stage I breast cancer is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience. The client who has a ruptured appendix is less stable and at high risk for infection/sepsis a more experienced nurse is required. The client with a fractured femur is at high risk for clotting, infection, and aspiration owing to the surgery a more experienced nurse would be better. The client with coronary artery disease is having high-risk surgery with risk for multiple complications and requires an experienced operating room nurse

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? It affects only young people. The client has dyspnea. The client is coughing. The client is symptom-free between exacerbations.

The client is symptom-free between exacerbations The client may be completely symptom-free between exacerbations. Asthma affects people of all ages. Dyspnea is a common symptom of many chronic lung diseases. Coughing occurs in many acute and chronic lung diseases.

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? The client will be treated for 5 to 7 days. The client will require IV antibiotics for 7 to 10 days. The client will complete 6 days of therapy. The client must be afebrile for 24 hours.

The client will be treated for 5 to 7 days Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? "Handwashing is the best way to prevent transmission." "I should avoid kissing and shaking hands." "It is best to cough and sneeze into my upper sleeve." "The intranasal vaccine can be given to everybody in the family."

The intranasal vaccine can be given to everybody in the family The intranasal flu vaccine is approved for healthy clients ages 2 to 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A new recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand.

What is the function of the turbinates? They decrease the weight of the skull on the neck. They increase the surface area of the nose for heating and filtering. They move inspired particles from nose to throat for removal. They separate two nasal passages down the middle.

They increase the surface area of the nose The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx. The paranasal sinuses are air-filled cavities that decrease the weight of the skull. The cilia are responsible for moving inspired particles to the throat so they can be swallowed or expectorated. The septum is the cartilage that separates the nasal cavity into two passages.

Why is it important to wear sterile gloves during a dressing change? They protect the client from infection. They protect the nurse from infection. They protect both the client and the nurse from infection. Their use prevents lawsuits.

They protect both the client and the nurse Standard Precautions and infection control protect both the nurse and the client from infection, not just the client or just the nurse. Preventing lawsuits is not the purpose of wearing sterile gloves.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? Chest x-ray Complete blood count (CBC) Tuberculosis (TB) skin test Throat culture

Throat culture A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

A client has a fever of 104° F (40° C). In which direction, if any, does this shift the oxygen-hemoglobin dissociation curve? Down To the left To the right Will not shift

To the right A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation. The curve does not move up or down on the vertical axis. Moving to the left would cause hemoglobin to dissociate oxygen less easily.

The nurse is planning care for a client with hypocalcemia. Which nursing action is appropriate to delegate to unlicensed assistive personnel (UAP)? Collaborating with the dietitian to provide calcium-rich foods for the client Evaluating the client's laboratory results Implementing seizure precautions for the client Transferring the client from the bed to a stretcher using a lift sheet Correct

Transferring the client from the bed to a stretcher using a lift sheet Transferring clients is a nursing skill that is included in UAP education and scope of practice. Collaborating with the dietitian, evaluating the client's laboratory results, and implementing seizure precautions all require broader education and scope of practice and should be done by licensed nursing personnel.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? Keeping the head of the bed elevated 30 to 45 degrees Performing oral care after suctioning the oropharynx Washing hands and donning gloves prior to the procedure Wearing a disposable particulate mask respirator and protective eyewear

Wearing a disposable particulate mask respirator and protective eyewear To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. Keeping the head of the bed elevated 30 to 45 degrees is not the most important precaution. Performing oral care is a comfort measure. Washing hands and donning gloves is necessary, but not the most important measure.

A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? "Fast thinking! She really needs to rest after the night she had." "Get the information now, or I'll report you for not doing your job." "Never mind—I will do it myself." "Weigh her now. We need her weight daily, at the same time." Correct

Weigh her now The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the client, assessing the client's fluid balance is more important. The responses that the client needed the rest, telling the nursing assistant to get the information now or she'll be reported, or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the client. She should not be dismissed and belittled by the nurse.

The nurse is instructing a client who is being discharged with a diagnosis of congestive heart failure (CHF). Which client statement indicates a correct understanding of CHF? "I can gain 2 pounds of water a day without risk." "I should call my provider if I gain more than 1 pound a week." "Weighing myself daily can determine if my caloric intake is adequate." "Weighing myself daily can reveal increased fluid retention."

Weighing myself daily can reveal increased fluid retention Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound of weight gained (after the first half-pound) equates to 500 mL of retained water. The client should be weighed at the same time every day (before breakfast) on the same scale. The client should call the health care provider if more than 1 or 2 pounds are gained in a 24-hour period or if more than 3 pounds are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.

The client says, "I hate this stupid COPD." What is the best response by the nurse? "Then you need to stop smoking." "What is bothering you?" "Why do you feel this way?" "You will get used to it."

What is bothering you Encourage the client, and the family, to express their feelings about limitations on their lifestyle and about disease progression. This is not the time to lecture the client regarding his smoking habits; the client is expressing a need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. The client's feelings should never be minimized.

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified

Written consultation of 2 noninvolved physicians - In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You are not contagious unless you stop taking your medication." "You will not be contagious to the people you have been living with." "You will have to take these medications for at least 1 year." Incorrect "Your sputum may turn a rust color as your condition gets better."

You will not be contagious to the people you have been living with The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? (Select all that apply.) Blood serum glucose Blood pressure Pulse rate and quality Urinary output Urine specific gravity levels

everything but glucose The two most important areas to monitor during rehydration are pulse rate and quality and urine output however, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is also important to monitor during rehydration. Blood glucose changes do not have a direct relation to a client's rehydration status.

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 7.0 mEq/L. What does the nurse include in the client's medication teaching? (Select all that apply.) Daily weights are a poor indicator of fluid loss or gain. Diuretics can lead to fluid and electrolyte imbalances. Diuretics increase fluid retention. Laxatives can lead to fluid imbalance. It is important to weigh daily at the same time.

fluid & electrolyte imbalances, laxative lead to imbalance, & weigh daily same time Diuretics decrease fluid retention and increase loss of fluids, thus can lead to fluid and electrolyte imbalances. Laxatives can also lead to fluid imbalance. Daily weight recording is a good indicator of fluid retention. Clients should be taught to weigh themselves at the same time, in the same clothing, and on the same scale.

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery

glass of juice - Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling. The nurse should confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse should document this in the client's information as well. The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (Select all that apply.) Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea. The client should take them at bedtime. The client is generally not contagious after 2 to 3 consecutive weeks of treatment. These medications must be taken for 2 years. These medications may cause kidney failure.

not taking the meds & may cause nausea Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this. The client is generally not contagious after 2 to 3 weeks of consecutive treatment and improvement in the condition has been observed. The combination regimen for treatment of TB has decreased treatment time from 6 to 12 months to 6 months. TB medications may cause liver failure, not kidney failure