Med Surg Exam 2 Questions

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. Take as deep a breath as possible. 2. Stand up (unless you have a physical disability). 3. Place the meter in your mouth, and close your lips around the mouthpiece. 4. Make sure the device reads zero or is at base level. 5. Blow out as hard and as fast as possible for 1 to 2 seconds. 6. Write down the value obtained. 7. Repeat the process two additional times, and record the highest number in your chart. a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4

a. 4, 2, 1, 3, 5, 6, 7 The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the clients chart.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

a. A 24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.) a. A lack of vitamin D can lead to rickets. b. Calcitonin increases serum calcium levels. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. e. Thyroxine stimulates estrogen release.

a. A lack of vitamin D can lead to rickets. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

a. Acetaminophen (Tylenol) All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

a. Acupuncture b. Stretching d. Tai chi There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

a. Adherence to the antibiotic regimen c. Eating high-protein and high-carbohydrate foods e. Proper use of the intravenous equipment The client going home with chronic osteomyelitis will need long-term antibiotic therapyfirst intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.) a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site. d. Place a heating pad at the site of the injury. e. Keep the extremity in a dependent position.

a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site. The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

a. Administer oxygen via nasal cannula. The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the clients white blood cell count. c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively.

a. Administer preoperative antibiotic as ordered. To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

a. Alcohol b. Caffeine d. Carbonated beverages e. Vitamin D Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the clients usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

a. Allow the client uninterrupted rest time. b. Assess the clients usual bedtime routine. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill. Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the clients legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

a. Apply an abduction pillow to the clients legs. c. Place pillows under the heels to keep them off the bed. e. Take and record vital signs per unit/facility policy. The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the clients nose. d. Turn the client every 2 hours or as needed.

a. Apply water-soluble ointment to nares and lips. Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

a. Applying water-soluble lip balm to the clients lips d. Reminding the client to cough and deep breathe often The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

a. Arrange a home safety evaluation. This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the clients condition at discharge.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

a. Ask the client about fear of falling. Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. d. Use a vibrating positive expiratory pressure device. Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the clients ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A client is distressed at body changes related to kyphosis. What response by the nurse is best? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client safety is more important than looks.

a. Ask the client to explain more about these feelings. Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the clients feelings as possible. Explaining that the changes are irreversible discounts the clients feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the clients neck for redness and swelling.

a. Ask the client to gargle with mouthwash containing lidocaine. Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the clients neck, but these options do not decrease the clients discomfort.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

a. Assess medication records for steroid use. Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

a. Assess neurovascular status in both legs. This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

A client is in the internal medicine clinic reporting bone pain. The clients alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate? a. Assess the client for leg bowing. b. Facilitate an oncology workup. c. Instruct the client on fluid restrictions. d. Teach the client about ibuprofen (Motrin).

a. Assess the client for leg bowing. This client has manifestations of Pagets disease. The nurse should assess for other manifestations such as bowing of the legs. Other care measures can be instituted once the client has a confirmed diagnosis.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Bakers cysts. b. Inspect the clients feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

a. Assess the client for the presence of subcutaneous nodules or Bakers cysts. Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the clients psychosocial needs? a. Assess the clients coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

a. Assess the clients coping skills and support systems. The first step in the nursing process is assessment. The nurse should assess coping skills and possible support systems that will be helpful in this clients treatment. Explaining that a limb salvage procedure will extend life does not address the clients psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the clients culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

a. Assess the clients culture more thoroughly. The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

a. Assess the clients lung sounds. The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

a. Assess the clients oxygen saturation. This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.) a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. c. Institute seizure precautions for the client. d. Instruct the client to call for help out of bed. e. Place the client on a 1500-mL fluid restriction.

a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. d. Instruct the client to call for help out of bed. The client is exhibiting manifestations of possible hypercalcemia. This disorder is treated with increased fluids and loop diuretics. The nurse should assess the calcium level, consult with the provider, and instruct the client to call for help getting out of bed due to possible fractures and weakness. The client does not need seizure precautions or fluid restrictions.

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best? a. Assess the neurovascular status of the right leg. b. Document the findings in the clients chart. c. Elevate the left leg on at least two pillows. d. Notify the provider of the findings immediately.

a. Assess the neurovascular status of the right leg. The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.

a. Assess the pedal pulses. These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a providers prescription.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

a. Assistance with activities of daily living A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

a. Attends meetings of a book club All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.

a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects. MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.) a. Avoid drinking fluids just before and during meals. b. Rest before meals if you have dyspnea. c. Have about six small meals a day. d. Eat high-fiber foods to promote gastric emptying. e. Increase carbohydrate intake for energy.

a. Avoid drinking fluids just before and during meals. b. Rest before meals if you have dyspnea. c. Have about six small meals a day. Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the clients risk of for acidosis.

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. Avoid large crowds or people who are ill. b. Stay upright for 1 hour after taking this drug. c. This drug may cause your hair to fall out. d. You may double the dose if pain is severe.

a. Avoid large crowds or people who are ill. This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

When assessing gait, what features does the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness

a. Balance b. Ease of stride d. Length of stride e. Steadiness To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion.

A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate? a. Bending forward from the hips b. Sitting upright with arms outstretched c. Walking across the room and back d. Walking with both eyes closed

a. Bending forward from the hips To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct.

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.) a. Bone changes lead to potential safety risks. b. Increased bone density leads to stiffness. c. Osteoarthritis occurs due to cartilage degeneration. d. Osteoporosis is a universal occurrence. e. Some muscle tissue atrophy occurs with aging.

a. Bone changes lead to potential safety risks. c. Osteoarthritis occurs due to cartilage degeneration. e. Some muscle tissue atrophy occurs with aging. Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases.

The clients chart indicates genu varum. What does the nurse understand this to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature

a. Bow-legged Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower. Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

a. Cognition b. Dexterity d. Range of motion e. Vision The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

a. Collect the nasal drainage on a piece of filter paper. The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the clients risk for infection.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

a. Consult with the health care provider about administering both drugs to the client. Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

a. Consult with the provider about an x-ray. Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowlers position. d. Ask the client to perform deep-breathing exercises.

a. Contact the provider and prepare for intubation. Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves. The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

a. Creatinine: 3.9 mg/dL Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

a. Dentist With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.

a. Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

a. Draining sinus tracts c. Presence of foot ulcers Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. Drink 1 to 2 liters of water each day. b. Have 10 to 12 ounces of juice a day. c. Liver is a good source of iron. d. Never eat hard cheeses or sardines.

a. Drink 1 to 2 liters of water each day. Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash Systemic lupus erythematosus (SLE) b. Esophageal dysmotility Systemic sclerosis c. Excess uric acid excretion Gout d. Footdrop and paresthesias Osteoarthritis e. Vasculitis causing organ damage Rheumatoid arthritis

a. Dry, scaly skin rash Systemic lupus erythematosus (SLE) b. Esophageal dysmotility Systemic sclerosis e. Vasculitis causing organ damage Rheumatoid arthritis A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema Increased capillary permeability b. Pallor Increased blood blow to the area c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism e. Tingling A release of histamine

a. Edema Increased capillary permeability c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.) a. Electromyography b. Muscle biopsy c. Nerve conduction studies d. Serum aldolase e. Serum creatinine kinase

a. Electromyography b. Muscle biopsy d. Serum aldolase e. Serum creatinine kinase Diagnostic testing for muscular dystrophy includes electromyography, muscle biopsy, serum aldolase and creatinine kinase levels. Nerve conduction is not related to this disorder.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the clients patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. d. Re-position the client every 2 hours. Postoperative care for a client who has ORIF of the hip includes elevating the clients heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

a. Encourage deep breathing and coughing. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

a. Encourage oral rinsing after fluticasone administration. The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best? a. Ensure the client gets 15 minutes of sun exposure daily. b. Give the client daily vitamin D injections. c. Hide vitamin D supplements in favorite foods. d. Plan to serve foods naturally high in vitamin D.

a. Ensure the client gets 15 minutes of sun exposure daily. Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Find an activity that you enjoy and will keep your hands busy. b. Keep snacks like potato chips on hand to nibble on. c. Identify a punishment for yourself in case you backslide. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking.

a. Find an activity that you enjoy and will keep your hands busy. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking. The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

What information does the nurse teach a womens group about osteoporosis? a. For 5 years after menopause you lose 2% of bone mass yearly. b. Men actually have higher rates of the disease but are underdiagnosed. c. There is no way to prevent or slow osteoporosis after menopause. d. Women and men have an equal chance of getting osteoporosis.

a. For 5 years after menopause you lose 2% of bone mass yearly. For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this clients teaching? (Select all that apply.) a. Frequently assess the ergonomics of the equipment being used. b. Take breaks to stretch fingers and wrists during working hours. c. Do not participate in activities that require repetitive actions. d. Take ibuprofen (Motrin) to decrease pain and swelling in wrists. e. Adjust chair height to allow for good posture.

a. Frequently assess the ergonomics of the equipment being used. b. Take breaks to stretch fingers and wrists during working hours. e. Adjust chair height to allow for good posture. Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

a. Giving subcutaneous injections Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to selfadminister the medication. The other options are not appropriate for etanercept.

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

a. Grab bars to reach high items b. Long-handled bath scrub brush d. Toothbrush with built-up handle Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg.

a. Have adequate help to transfer the client. The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education? a. High school football team b. High school homeroom class c. Middle-aged men d. Older adult women

a. High school football team Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I cant be exposed to the sun, I have been using a tanning bed.

a. I always wear long sleeves, pants, and a hat when outdoors. Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I can drive myself home after the procedure. b. I will monitor the puncture site for signs of infection. c. I can start walking tomorrow and increase my activity slowly. d. I will remove the dressing the day after discharge.

a. I can drive myself home after the procedure. Before discharge, a client who has a vertebroplasty should be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. I held the clients morning bronchodilator medication. b. The client is ready to go down to radiology for this examination. c. Physical therapy states the client can run on a treadmill. d. I advised the client not to smoke for 6 hours prior to the test. e. The client is alert and can follow your commands.

a. I held the clients morning bronchodilator medication. d. I advised the client not to smoke for 6 hours prior to the test. e. The client is alert and can follow your commands. To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next? a. Immobilize the left arm. b. Assess the clients distal pulse. c. Monitor for signs of infection. d. Administer prescribed steroids.

a. Immobilize the left arm. A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the clients arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

a. Increased pulmonary pressure creating a higher workload on the right side of the heart Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

a. Initiate Standard Precautions. The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct? a. Inspect the clients distal finger joints. b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes. d. Perform range of motion on the clients wrists.

a. Inspect the clients distal finger joints. Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

a. It leads to minimal blood loss. b. It allows for early ambulation. e. It promotes healing. External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the clients safety while on this medication? (Select all that apply.) a. Keep an intravenous line dedicated strictly to the infusion. b. Teach the client that this medication increases pulmonary pressures. c. Ensure that there is always a backup drug cassette available. d. Start a large-bore peripheral intravenous line. e. Use strict aseptic technique when using the drug delivery system.

a. Keep an intravenous line dedicated strictly to the infusion. c. Ensure that there is always a backup drug cassette available. e. Use strict aseptic technique when using the drug delivery system. Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine (Demerol) 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

a. Meperidine (Demerol) 50 mg IV every 4 hours Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first? a. Raise the arm above the level of the heart. b. Encourage range of motion. c. Apply heat to the affected hand. d. Bivalve the cast to decrease pressure.

a. Raise the arm above the level of the heart. Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

a. Remove the medical alert bracelet from the fractured arm. A clients medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond? a. Skeletal traction will assist in realigning your fractured bone. b. This treatment will prevent future complications and back pain. c. Traction decreases muscle spasms that occur with a fracture. d. This type of traction minimizes damage as a result of fracture treatment.

a. Skeletal traction will assist in realigning your fractured bone. Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

a. Stridor d. Ecchymosis behind the ear Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called battle sign and indicates basilar skull fracture. Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. No difficulties are expected with ADLs. c. The client is unable to perform ADLs alone. d. The client would need near-total assistance with ADLs.

a. The client is able to perform ADLs but not lift some items. This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects.

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. The device has been custom made specifically for you. b. Your prosthetic is good for work but not for exercising. c. A prosthetist will clean your inserts for you each month. d. Make sure that you wear the correct liners with your prosthetic. e. I have scheduled a follow-up appointment for you.

a. The device has been custom made specifically for you. d. Make sure that you wear the correct liners with your prosthetic. e. I have scheduled a follow-up appointment for you. A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the clients level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

a. Visual hallucinations d. Impaired judgment Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

While obtaining a clients health history, the client states, I am allergic to avocados. Which responses by the nurse are best? (Select all that apply.) a. What response do you have when you eat avocados? b. I will remove any avocados that are on your lunch tray. c. When was the last time you ate foods containing avocados? d. I will document this in your record so all of your providers will know. e. Have you ever been treated for this allergic reaction?

a. What response do you have when you eat avocados? d. I will document this in your record so all of your providers will know. e. Have you ever been treated for this allergic reaction? Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the clients medical record. The nurse should collaborate with food services to ensure no avocados are placed on the clients meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the clients plan of care.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.

a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowlers position to assist in avoiding aspiration. Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. Your feet have less blood flow, so healing is slower. b. The bones in your feet are hard to operate on. c. The surrounding bones and tissue are damaged. d. Your feet bear weight so they never really heal.

a. Your feet have less blood flow, so healing is slower. The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery. The other explanations are not correct.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a.22-year-old client with asthma b.Client who had a cholecystectomy last year c.Client with well-controlled diabetes d.Healthy 72-year-old client e.Client who is taking medication for hypertension

a.22-year-old client with asthma c.Client with well-controlled diabetes d.Healthy 72-year-old client e.Client who is taking medication for hypertension Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

A nurse admits a client from the emergency department. Client data are listed below: History: 70 y/o, hx of diabetes, on insulin twice a day, reports new-onset dyspnea and productive cough Physical assessment: Crackles and rhonchi heard throughout the lungs, dullness to percussion LLL, afebrile, oriented to person only Lab values: WBC: 5200/mm3, PaO2 on room air 65 mmHg What action by the nurse is the priority? a.Administer oxygen at 4 liters per nasal cannula. b.Begin broad-spectrum antibiotics. c.Collect a sputum sample for culture. d.Start an IV of normal saline at 50 mL/hr.

a.Administer oxygen at 4 liters per nasal cannula. All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so begin oxygen administration and titrate it to maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then begin antibiotics.

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.) a.Amoxicillin (Amoxil) b.Ciprofloxacin (Cipro) c.Doxycycline (Vibramycin) d.Ethambutol (Myambutol) e.Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra)

a.Amoxicillin (Amoxil) b.Ciprofloxacin (Cipro) c.Doxycycline (Vibramycin) Amoxicillin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax. Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections and other common infections.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a.Antibiotics started before admission b.Blood cultures obtained within 20 minutes c.Chest x-ray obtained within 30 minutes d.Pulse oximetry obtained on all clients

a.Antibiotics started before admission Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a.Ask the spouse to explain the fear of visiting in further detail. b.Inform the spouse the precautions are meant to keep other clients safe. c.Show the spouse how to follow the isolation precautions to avoid illness. d.Tell the spouse that he or she has already been exposed, so its safe to visit.

a.Ask the spouse to explain the fear of visiting in further detail. The nurse needs to obtain further information about the spouses specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse its safe to visit is demeaning of the spouses feelings.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed e.Suctioning deeply every 4 hours

a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best? a.Breathing so quickly can be dehydrating. b.Everyone with pneumonia is dehydrated. c.This is really just to administer your antibiotics. d.Why do you think you are so dehydrated?

a.Breathing so quickly can be dehydrating. Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a.Educating the client on adherence to the treatment regimen b.Encouraging the client to eat a well-balanced diet c.Informing the client about follow-up sputum cultures d.Teaching the client ways to balance rest with activity

a.Educating the client on adherence to the treatment regimen The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

b. 21% Room air is 21% oxygen.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

b. A 52-year-old in a tripod position using accessory muscles to breathe The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

b. Absent breath sounds Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.

A nurse cares for a client who had a long-leg cast applied last week. The client states, I cannot seem to catch my breath and I feel a bit light-headed. Which action should the nurse take next? a. Auscultate the clients lung fields anteriorly and posteriorly. b. Administer oxygen to keep saturations greater than 92%. c. Check the clients blood glucose level. d. Ask the client to take deep breaths.

b. Administer oxygen to keep saturations greater than 92%. The clients symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the clients pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

b. Antibodies lead to inflammation. RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

A client with Pagets disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering ibuprofen (Motrin) b. Applying a heating pad c. Providing a massage d. Referring the client to a support group e. Using a bed cradle to lift sheets off the feet

b. Applying a heating pad c. Providing a massage Comfort measures for Pagets disease include heat and massage. Administering medications and referrals are done by the nurse. A bed cradle is not necessary.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the clients pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

b. Ask about medications the client is currently taking. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the clients history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks.

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a. Administer sedation as prescribed. b. Assess for seafood or iodine allergy. c. Ensure that the client has no metal on the body. d. Provide preprocedure pain medication.

b. Assess for seafood or iodine allergy. Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority? a. Allow the client to rest in a position of comfort. b. Assess the clients cardiac and respiratory systems. c. Assist the client with ambulating and position changes. d. Position the client on one side propped with pillows.

b. Assess the clients cardiac and respiratory systems. This degree of curvature of the spine affects cardiac and respiratory function. The nurses priority is to assess those systems. Positioning is up to the client. The client may or may not need assistance with movement.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the clients level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

b. Assess the clients level of consciousness. Assessing the clients level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone Disrupts the production of pathways of inflammatory mediators

b. Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

b. Client with a red, hot, swollen right wrist All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) Acute gout b. Colchicine (Colcrys) Acute gout c. Febuxostat (Uloric) Chronic gout d. Indomethacin (Indocin) Acute gout e. Probenecid (Benemid) Chronic gout

b. Colchicine (Colcrys) Acute gout c. Febuxostat (Uloric) Chronic gout d. Indomethacin (Indocin) Acute gout e. Probenecid (Benemid) Chronic gout Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

b. Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the clients oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

b. Determine if the client can switch to a nasal cannula during the meal. Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. Are you taking any medications or herbal supplements? b. Do you have any chronic breathing problems? c. How often do you perform aerobic exercise? d. What is your occupation and what are your hobbies?

b. Do you have any chronic breathing problems? The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.) a. What color is your sputum? b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? d. Do you walk upstairs every day? e. Have you lost any weight lately?

b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? e. Have you lost any weight lately? Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the clients sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care? a. Place pillows between the clients knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

b. Encourage range-of-motion exercises. Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

b. Ensure informed consent is on the chart. Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

b. Ensure that a consent for transfusion is on the chart. The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

A client is having a myelography. What action by the nurse is most important? a. Assess serum aspartate aminotransferase (AST) levels. b. Ensure that informed consent is on the chart. c. Position the client flat after the procedure. d. Reinforce the dressing if it becomes saturated.

b. Ensure that informed consent is on the chart. This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Feltys syndrome c. Joint deformity d. Low-grade fever e. Weight loss

b. Feltys syndrome c. Joint deformity e. Weight loss Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. Youre still taking your diabetic medication, right?

b. Have you been taking glucosamine supplements? All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

b. Help the client create backup plans to minimize disruption. SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

b. Hypertension c. Leukemia d. Cocaine use Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

b. Ice packs Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

b. Intact skin behind the ears Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate? a. Drink at least 8 ounces of water with it. b. Make appointments to come get your shot. c. Sit upright for 30 to 60 minutes after taking it. d. Take the drug on an empty stomach.

b. Make appointments to come get your shot. Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching? a. Add peppermint oil to the humidifier to relax the airway. b. Make sure you clean the humidifier to prevent infection. c. Keep the humidifier filled with water at all times. d. Use the humidifier when you sleep, even during daytime naps.

b. Make sure you clean the humidifier to prevent infection. Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used while awake and asleep.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

b. Measure and compare cuff pressures. Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

An older clients serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia d. Potential for metastatic cancer or Pagets disease e. Recent bone fracture in a healing stage

b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Pagets disease, or healing bone fractures will elevate calcium.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the clients peripheral pulses. d. Obtain blood and sputum cultures.

b. Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the clients oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

b. Numbness in the extremity The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

b. Patient-controlled analgesia (PCA) pump with morphine The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

A client has a bone density score of 2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

b. Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than 2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

b. Prepare to administer epoetin alfa (Epogen). This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

b. The client has joined a book club that meets at the library. The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

b. The client places his or her hands on his or her abdomen. To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomento create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. I will consult the speech therapist to ensure you are swallowing properly. b. This is normal after surgery. What types of food do you like to eat? c. I will ask the dietitian to change the consistency of the food in your diet. d. Replacement of protein, calories, and water is very important after surgery.

b. This is normal after surgery. What types of food do you like to eat? Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the clients concerns.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

b. Tracheal deviation c. Sudden onset of shortness of breath Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

b. Tracheal deviation d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds

b. Traction weights are resting on the floor The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The clients blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

b. Tuck the chin down when swallowing. The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

b. Urinary output c. Blood pressure e. Skin color With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the clients heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching? a. I will stay away from smokers to minimize inhalation of secondhand smoke. b. When I speak, I will whisper rather than use a normal tone of voice. c. For the next several weeks, I will not lift more than 10 pounds. d. I will drink at least three quarts of water each day to stay hydrated.

b. When I speak, I will whisper rather than use a normal tone of voice. Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, to stay hydrated, and to use stool softeners.

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? a.Albumin: 5.1 g/dL b.Alanine aminotransferase (ALT): 180 U/L c.Red blood cell (RBC) count: 5.2/mm3 d.White blood cell (WBC) count: 12,500/mm3

b.Alanine aminotransferase (ALT): 180 U/L INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a.Ask the client what foods cause trouble swallowing. b.Assess the client for pain when swallowing. c.Determine if the client can swallow saliva. d.Palpate the clients jaw while swallowing.

b.Assess the client for pain when swallowing. Odynophagia is painful swallowing. The nurse should assess the client for this either by asking or by having the client attempt to drink water. It is not related to specific foods and is not assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but it would be a serious situation.

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a.Admit the clients on Contact Precautions. b.Cohort the clients in the same area of the unit. c.Do not allow pregnant caregivers to care for these clients. d.Place the clients on enhanced Droplet Precautions.

b.Cohort the clients in the same area of the unit. Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate? a.Arrange for immediate hospitalization. b.Facilitate polymerase chain reaction testing. c.Have the client produce a sputum sample. d.Obtain two sets of blood cultures.

b.Facilitate polymerase chain reaction testing. Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. Hospitalization may or may not be needed but is not the most important action. The client may or may not be able to produce sputum, but sputum cultures for this disease must be obtained via deep suctioning. Blood cultures will be negative.

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best? a.Collect a sputum sample for culture by deep suctioning. b.Inform the client that antibiotics will be needed for 60 days. c.Place the client on Airborne Precautions immediately. d.Tell the client that directly observed therapy is needed.

b.Inform the client that antibiotics will be needed for 60 days. This client has manifestations of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are not needed. Anthrax is not transmissible from person to person, so Standard Precautions are adequate. Directly observed therapy is often used for tuberculosis.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a.Blood urea nitrogen (BUN): 19 mg/dL b.International normalized ratio (INR): 6.3 c.Prothrombin time: 35 seconds d.Serum sodium: 130 mEq/L e.White blood cell (WBC) count: 72,000/mm3

b.International normalized ratio (INR): 6.3 c.Prothrombin time: 35 seconds Rifampin can cause liver damage, evidenced by the clients high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this clients problem.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a.Chest x-rays are always ordered when we suspect pneumonia. b.Older people often have vague symptoms, so an x-ray is essential. c.The x-ray can be done and read before laboratory work is reported. d.We are testing for any possible source of infection in the client.

b.Older people often have vague symptoms, so an x-ray is essential. It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The xray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

Which teaching point is most important for the client with bacterial pharyngitis? a.Gargle with warm salt water. b.Take all antibiotics as directed. c.Use a humidifier in the bedroom. d.Wash hands frequently

b.Take all antibiotics as directed. Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. Press down firmly on the canister to release one dose of medication. 2. Breathe in slowly and deeply. 3. Shake the whole unit vigorously three or four times. 4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 5. Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece. 6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds. a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

c. 4, 3, 5, 1, 2, 6 The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

c. A 55-year-old woman who is 50 pounds overweight The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

c. Administer oxygen to keep saturations greater than 94%. e. Administer prescribed albuterol (Proventil) inhaler. Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

c. Assess the clients gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

c. Assist the client to choose a communication method. The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the clients airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this clients gait should not be impacted by a total laryngectomy and therefore is not a priority.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

c. Barbiturates d. Corticosteroids e. Loop diuretics Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry. b. Clients heart rate is 55 beats/min. Nurse withholds pain medication. c. Client has reduced breath sounds. Nurse calls physician immediately. d. Clients respiratory rate is 18 breaths/min. Nurse decreases oxygen flow rate.

c. Client has reduced breath sounds. Nurse calls physician immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the clients heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

c. Client taking raloxifene (Evista) who reports unilateral calf swelling The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. Do you have a strong support system? b. What do you understand about your disease? c. Do you experience shortness of breath with basic activities? d. What medications are you prescribed to take each day?

c. Do you experience shortness of breath with basic activities? Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the clients support systems, current knowledge, and medications, these questions do not address the clients appearance.

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching? a. Take an antibiotic each day. b. Contact your provider to obtain genetic screening. c. Eat a well-balanced, nutritious diet. d. Plan to exercise for 30 minutes every day.

c. Eat a well-balanced, nutritious diet. Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

A client is scheduled for a bone biopsy. What action by the nurse takes priority? a. Administering the preoperative medications b. Answering any questions about the procedure c. Ensuring that informed consent is on the chart d. Showing the clients family where to wait

c. Ensuring that informed consent is on the chart The priority is to ensure that informed consent is on the chart. The preoperative medications should not be administered until the nurse is confident the procedure will occur and the client has already signed the consent, if the medications include anxiolytics or sedatives or opioids. The provider should answer questions about the procedure. The nurse does show the family where to wait, but this is not the priority and could be delegated.

A client has a metastatic bone tumor. What action by the nurse takes priority? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Handle the affected extremity with caution. d. Place the client on protective precautions.

c. Handle the affected extremity with caution. Bones invaded by tumors are very fragile and fracture easily. For client safety, the nurse handles the affected extremity with great care. Pain medication should be given to control pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

A hospitalized client is being treated for Ewings sarcoma. What action by the nurse is most important? a. Assessing and treating the client for pain as needed b. Educating the client on the disease and its treatment c. Handling and disposing of chemotherapeutic agents per policy d. Providing emotional support for the client and family

c. Handling and disposing of chemotherapeutic agents per policy All actions are appropriate for this client. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. I plan to wear my oxygen when I exercise and feel short of breath. b. I will use my portable oxygen when grilling burgers in the backyard. c. I plan to use cotton balls to cushion the oxygen tubing on my ears. d. I will only smoke while I am wearing my oxygen via nasal cannula.

c. I plan to use cotton balls to cushion the oxygen tubing on my ears. Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I wont wash my incision to keep it dry.

c. I will not sit with my legs crossed. There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all times in case I need it. b. I will take this medication when I start to experience an asthma attack. c. I will take this medication every morning to help prevent an acute attack. d. I will be weaned off this medication when I no longer need it.

c. I will take this medication every morning to help prevent an acute attack. Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will be certain to shake the inhaler well before I use it. b. It may take a while before I notice a change in my asthma. c. I will use the drug when I have an asthma attack. d. I will be careful not to let the drug escape out of my nose and mouth.

c. I will use the drug when I have an asthma attack. Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the clients part allows the drug to escape through the nose and mouth.

The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.

c. Immediately increase the flow rate. For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.

A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess? a. Inability to maintain adduction of the affected arm for more than 30 seconds b. Shoulder pain that is relieved with overhead stretches and at night c. Inability to initiate or maintain abduction of the affected arm at the shoulder d. Referred pain to the shoulder and arm opposite the affected shoulder

c. Inability to initiate or maintain abduction of the affected arm at the shoulder Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience referred pain to the opposite shoulder. Pain is usually more intense at night and with overhead activities.

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

c. Intravenous calcitonin The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.

The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond? a. I will ask the provider to change your medication to a drug that is less potent. b. Would you like me to use music therapy to distract you from your pain? c. It is unlikely you will become addicted when taking medicine for pain. d. Would you like me to give you acetaminophen (Tylenol) instead?

c. It is unlikely you will become addicted when taking medicine for pain. Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication.

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

c. Keep the client isolated from other clients with cystic fibrosis. Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating. The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynauds phenomenon. The UAP can adjust the room temperature for the clients comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed. Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan.

c. Notify the surgeon or anesthesia provider immediately. With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.

c. Notify your provider at once if you get a fever. Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

c. Omelet, soft whole wheat bread Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

An older client with diabetes is admitted with a heavily draining leg wound. The clients white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first? a. Administer acetaminophen (Tylenol). b. Educate the client on amputation. c. Place the client on contact isolation. d. Refer the client to the wound care nurse.

c. Place the client on contact isolation. In the presence of a heavily draining wound, the nurse should place the client on contact isolation. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted, but not as the first action.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

c. Post-microvascular bone transfer client whose distal leg is cool and pale This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

c. Raise the lower siderail on the affected side. Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system? a. Cancellous tissue b. Collagen matrix c. Red marrow d. Yellow marrow

c. Red marrow Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

c. Severe osteoporosis Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. There are a variety of support groups for people who have COPD. b. I will ask your provider to prescribe you with an antianxiety agent. c. Share any thoughts and feelings that cause you to limit social activities. d. Friends can be a good support system for clients with chronic disorders.

c. Share any thoughts and feelings that cause you to limit social activities. Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond? a. Since many of your family members are carriers, your children will also be carriers of the gene. b. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder. c. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested. d. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

c. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested. Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this clients teaching? a. Make a list of reasons why smoking is a bad habit. b. Rise slowly when getting out of bed in the morning. c. Smoking while taking this medication will increase your risk of a stroke. d. Stopping this medication suddenly increases your risk for a heart attack.

c. Smoking while taking this medication will increase your risk of a stroke. Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.

A nurse is providing education to a community womens group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week. Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. A little sedation will help you get some rest. b. Depression often accompanies fibromyalgia. c. This drug works in the brain to decrease pain. d. You will have more energy after taking this drug.

c. This drug works in the brain to decrease pain. Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, I dont want to live with only one leg. I should have died during the surgery. How should the nurse respond? a. Your vital signs are good, and you are doing just fine right now. b. Your children are waiting outside. Do you want them to grow up without a father? c. This is a big change for you. What support system do you have to help you cope? d. You will be able to do some of the same things as before you became disabled.

c. This is a big change for you. What support system do you have to help you cope? The client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping. The nurse should not ignore the clients feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being disabled as this labels the client and may fuel the clients poor body image.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond? a. This medication will treat your sleep apnea. b. This sedative will help you to sleep at night. c. This medication will promote daytime wakefulness. d. This analgesic will increase comfort while you sleep.

c. This medication will promote daytime wakefulness. Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. Lets ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers.

c. Try a paraffin wax dip 20 minutes before you quilt. Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

c. Tying a square knot at the back of the neck To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate.

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. Assess distal pulses for potential compartment syndrome. b. Turn the client every 3 to 4 hours to promote cast drying. c. Use a cloth-covered pillow to elevate the clients leg. d. Handle the cast with your fingertips to prevent indentations.

c. Use a cloth-covered pillow to elevate the clients leg. When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.

A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention? a. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate. b. Crackles are heard in bases. The nurse encourages the client to cough forcefully. c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

c. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator. Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond? a. Your children will be at high risk for the development of chronic obstructive pulmonary disease. b. I will contact a genetic counselor to discuss your condition. c. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke. d. This is a recessive gene and should have no impact on your health.

c. Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke. The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partners AAT levels. Contacting a genetic counselor may be helpful but does not address the clients current question.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a.Chlorpheniramine (Chlor-Trimeton) b.Diphenhydramine (Benadryl) c.Fexofenadine (Allegra) d.Hydroxyzine (Vistaril)

c.Fexofenadine (Allegra) First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a.I need to take extra vitamin C while on INH. b.I should take this medicine with milk or juice. c.I will take this medication on an empty stomach. d.My contact lenses will be permanently stained

c.I will take this medication on an empty stomach. INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a.Encourage between-meal snacks. b.Monitor temperature every 4 hours. c.Provide oral care every 4 hours. d.Report any new onset of cough.

c.Provide oral care every 4 hours. Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a.Ice packs may help with the facial pain. b.Limit fluids to dry out your sinuses. c.Try warm, moist heat packs on your face. d.We will schedule you for a computed tomography scan this week.

c.Try warm, moist heat packs on your face. This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

d. A 27-year-old client with a heart rate of 120 beats/min Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

d. A 74-year-old man who smokes and has a fractured pelvis Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the clients anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

d. Administer pain medication and encourage the client to take deep breaths. A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the clients discomfort and need to take deep breaths to prevent complications.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

d. Airway patency A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

d. Ask the client if he or she has ever been evaluated for sleep apnea. Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

d. Client with a fever and cough who is taking tofacitinib (Xeljanz) Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

d. Client with a spinal cord injury who cannot tolerate sitting up Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. Remove the traction when re-positioning the client. b. Inspect the clients skin when performing a bed bath. c. Provide pin care by using alcohol wipes to clean the sites. d. Ensure that the weights remain freely hanging at all times.

d. Ensure that the weights remain freely hanging at all times. Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the clients skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury? a. Hypertension b. Constipation c. Infection d. Hematuria

d. Hematuria The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. The pain you are feeling does not actually exist. b. This type of pain is common and will eventually go away. c. Would you like to learn how to use imagery to minimize your pain? d. How would you describe the pain that you are feeling?

d. How would you describe the pain that you are feeling? The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse mustassess the clients pain before determining the best action.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3 = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

d. Initiate oxygenation therapy to increase saturation to 92%. Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the clients hypoxia, which is the priority.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond? a. You are using the inhaler incorrectly. This medication should be taken daily. b. If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks. c. Tell me more about your fears related to feelings of breathlessness. d. It is important to use this type of inhaler every day. Lets identify potential community services to help you.

d. It is important to use this type of inhaler every day. Lets identify potential community services to help you. Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the clients financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the clients immediate concerns.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

d. Keep padded clamps at the bedside for use if the drainage system is interrupted. Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the devices manufacturer, not the provider.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the clients cheek.

d. Make sure the string is taped to the clients cheek. The string should be attached to the clients cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the clients airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the clients chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

d. Notify the provider immediately. Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next? a. Request a prescription to decrease the traction weight. b. Apply an antibiotic ointment and a clean dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage.

d. Obtain a prescription to culture the drainage. These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.

A client is admitted with a large draining wound on the leg. What action does the nurse take first? a. Administer ordered antibiotics. b. Insert an intravenous line. c. Give pain medications if needed. d. Obtain cultures of the leg wound.

d. Obtain cultures of the leg wound. The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority.

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

d. Occupation and hobbies Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a clients occupation and hobbies. Although it will be important for the nurse to assess the clients fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the clients neck circumference will not be an important part of a respiratory assessment.

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture? a. Sedentary lifestyle b. A 30pack-year smoking history c. Prescribed oral contraceptives d. Pagets disease

d. Pagets disease Pagets disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.

A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond? a. Elevate your arm on two pillows and get ice to apply to the cast. b. Continue to take ibuprofen (Motrin) until the swelling subsides. c. This is normal. A new cast will often feel a little tight for the first few days. d. Please come to the clinic today to have your arm checked by the provider.

d. Please come to the clinic today to have your arm checked by the provider. Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not reassure the client that this is normal.

A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) Normal value; no connective tissue disease b. Elevated sedimentation rate Rheumatoid arthritis c. Lowered albumin Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis e. Positive rheumatoid factor Possible kidney disease

d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis e. Positive rheumatoid factor Possible kidney disease The HLA-B27 is diagnostic for Reiters syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

d. Providing a verbal hand-off report to the facility As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

d. Roast beef with low-fat milk and a vitamin C supplement The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection? a. Wash the traction lines and sockets once a day. b. Release traction tension for 30 minutes twice a day. c. Do not place the traction weights on the floor. d. Schedule for pin care to be provided every shift.

d. Schedule for pin care to be provided every shift. To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the clients skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection.

The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first? a. Serum alkaline phosphatase (ALP): 108 units/L b. Serum aspartate aminotransferase (AST): 26 units/L c. Serum calcium: 10.2 mg/dL d. Serum phosphorus: 2 mg/dL

d. Serum phosphorus: 2 mg/dL A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

d. Stay with the client and have someone else call the provider immediately. This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

d. Storing the CPM machine under the bed after removal For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

d. The trachea is deviated toward the opposite side of the neck. A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the clients hands. d. Use an abduction pillow.

d. Use an abduction pillow. Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the clients white blood cell count. b. Culture any drainage from the wound. c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes.

d. Use aseptic technique for dressing changes. Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

d. Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

d. Visual acuity Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.

A client has an ingrown toenail. About what self-management measure does the nurse teach the client? a. Long-term antibiotic use b. Shoe padding c. Toenail trimming d. Warm moist soaks

d. Warm moist soaks Treatment of an ingrown toenail includes a podiatrist clipping away the ingrown part of the nail, warm moist soaks, and antibiotic ointment if needed. Antibiotics are not used long-term. Padding the shoes will not treat or prevent ingrown toenails. Clients should not attempt to trim ingrown nails themselves.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

d. When the tube becomes disconnected from the drainage system Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the clients risk for a pneumothorax.

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, The cast is loose enough to slide off. How should the nurse respond? a. Keep your arm above the level of your heart. b. As your muscles atrophy, the cast is expected to loosen. c. I will wrap a bandage around the cast to prevent it from slipping. d. You need a new cast now that the swelling is decreased.

d. You need a new cast now that the swelling is decreased. Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the clients skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the clients muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a.Intravenous amphotericin B b.Long-term antiinflammatories c.No specific treatment d.Oral fluconazole (Diflucan)

d.Oral fluconazole (Diflucan) Valley fever, or coccidioidomycosis, is a fungal infection. Many people do not need treatment and the disease resolves on its own. However, the presence of joint and muscle pain indicates a moderate infection that needs treatment with antifungal medications. IV amphotericin is reserved for pregnant women and those with severe infection. Anti-inflammatory medications may be used to treat muscle aches and pain but are not used long term.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a.Educate the client on oseltamivir (Tamiflu). b.Facilitate admission to the hospital. c.Instruct the client to have a flu vaccine. d.Teach the client to sneeze in the upper sleeve.

d.Teach the client to sneeze in the upper sleeve. Sneezing and coughing into ones sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a.Community social worker for Meals on Wheels b.Occupational therapy for job retraining c.Physical therapy for homebound therapy services d.Visiting Nurses for directly observed therapy

d.Visiting Nurses for directly observed therapy Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important? a.Are any family members also ill? b.Have you traveled recently? c.How long have you been ill? d.What is your occupation?

d.What is your occupation? Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.