Med surg- proctored ATI
A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
"A tissue sample might be obtained during the procedure." The nurse should inform the client that a tissue sample might be obtained during the procedure for biopsy testing.
A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include?
"Apply heat to your joints prior to exercising." The nurse should instruct the client to apply heat to the joints prior to exercising to increase mobility and reduce pain.
A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching?
"Eat protein with each meal." The nurse should instruct the client to eat meals that are high in protein and fat with low to moderate carbohydrate content. Protein should be included in every meal because it delays digestion, which helps reduce the manifestations of dumping syndrome.
A nurse is teaching a client who polycythemia vera about self-care measures. Which of the following interventions should the nurse include?
"Elevate your legs when sitting." Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.
A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery?
"I understand that I will have a permanent tracheostomy after the surgery." With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent.
A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following client statements indicates an understanding of the information?
"I will feel the urge to urinate following this procedure." After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will receive analgesics to help relieve this discomfort.
A nurse is providing discharge teaching to a client who is postoperative following rhinoplasty. Which of the following instructions should the nurse include?
"Lie on your back with your head elevated 30 degrees when resting." The nurse should instruct the client to rest in the semi-fowler's position to prevent aspiration of nasal secretions.
A nurse is providing discharge teaching to client who has osteoarthritis. Which of the following instructions should the nurse include?
"Rest frequently after periods of activity." The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve the pain, so performing activities at a comfortable pace with periods of rest is appropriate.
A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which of the following pieces of information should the nurse include in the teaching?
"The drainage tubes often are removed at the same time as the stitches." The nurse should instruct the client that the provider will remove the drainage tubes at the same time the stitches are removed, usually within 7 to 10 days.
A nurse is preparing a client for an electromyogram (EMG). Which of the following statements indicates that the client understands the pre-procedure teaching?
"This test will help my doctor know if my nerves are working correctly." An EMG shows electrical activity within the muscles during contraction. It is useful for discriminating between muscular dysfunction and nerve dysfunction.
A nurse is teaching a client who had a vaginal hysterectomy with a bilateral oophorectomy. Which of the following pieces of information should the nurse include in the teaching?
"Use a water-based lubricant when having sexual intercourse." Vaginal dryness is a manifestation of menopause after the ovaries are removed. The client may require a water-based lubricant when having sexual intercourse.
A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of the following pieces of information should the nurse give the client prior to the procedure?
"You can have mild sedative before the procedure." Some clients need mild sensation, especially when using an older closed MRI machine. Clients can feel claustrophobic and anxious as they slowly pass through what seems like a tunnel.
A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching?
"You can suck on popsicles to numb your mouth." The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth.
A nurse is providing postoperative discharge teaching to a client following panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching?
"You might experience manifestations of menopause." The nurse should inform the client that a panhysterectomy includes the removal of the uterus and the ovaries, which might cause manifestations of menopause (e.g., hot flashes, night sweats, and vaginal dryness).
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?
"You should cut the opening of the skin barrier one-eight inch wider than the stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to minimize irritation of the skin from exposure to urine.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply).
"You'll have considerably less pain with the traction in place." "The traction will help decrease muscle spasms." "The weights act as a pulling force to keep your leg and hip still." Pain is usually more severe without the traction. Buck's extension traction uses weights to help decrease muscle spasms. Typically, 2.3 to5.5 kg (5 to 10 lb) of force helps stabilize the hip and legs preoperatively.
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the nearest whole number.)
167 mL/hr
A nurse is caring for a client who has tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse?
A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?
Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.
A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder?
Absence of hair on the legs A progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?
Add cabbage to the diet. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage, cauliflower, and broccoli, are high in fiber.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the expect?
Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors increases the client's risk of developing breast cancer?
Age over 50 years A female client who is over 50 years of age has increased risk of developing breast cancer.
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?
Aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following should the nurse expect in the client's affected extremity?
Ankle swelling The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. Other manifestations can include brown pigmentation and cellulitis.
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?
Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.
A nurse is assessing a provider with performing a paracentesis on a client. Which of the following actions should the nurse take?
Ask the client to empty his bladder before the procedure. The nurse should ask the client to empty his bladder before the procedure to prevent injury to the bladder.
A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection?
Blood pressure 160/90 mmHg Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?
Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find?
Bronze pigmentation of the skin A client who has Addison's disease will have a darkening of the skin on both exposed and unexposed parts of the body due to hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex).
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs? (Select all that apply).
COPD Cancer Parkinson's disease Major burns Clients who have COPD develop hypermetabolism as a result of the increased amount of energy used to breathe. Cancer can cause a number of metabolic changes, including hypermetabolism as a result of the tumor growth. Clients who have Parkinson's disease develop hypermetabolism because they burn calories due to muscular rigidity. Finally, clients who have major burns may develop severe metabolic stress, which includes hypermetabolism and hypercatabolism.
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?
Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.
A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care?
Change the collection pouch in the early morning The nurse should plan to change the urinary collection pouch in the early morning when urine output is reduced.
A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care?
Check the client's urine specific gravity The nurse should check the client's urine specific gravity to assess for fluid volume overload.
A nurse is preparing to administer packed RBC's to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply)
Check to determine the packed RBC's are less than 1 week old Ask another nurse to check the packed RBC's label against the medical record Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBC's are less than 1 week old; if the blood is older, the RBC's become fragile, break easily, and release potassium into the blood stream. In addition, the nurse should ask another nurse to check the packed RBC's label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBC's.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?
Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear?
Cochlea Meniere's disease is a condition of the inner ear in which excess fluid distorts that inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.
A nurse in a dermatology clinic is using the ABCDE method while screening several skin lesions for skin cancer on a client. Which of the following findings should the nurse report to the provider?
Color variation within a lesion The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of the lesion.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client).
Current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump the nurse should monitor the client for which of the following findings?
Diaphoresis The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.
A nurse is assessing a client who has Graves disease. Which of the following findings should the nurse expect the client to display?
Difficulty sleeping A client who has Graves' disease can have difficulty sleeping and anxiety due to the overproduction of thyroid hormone.
A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications?
Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor client's ECG's carefully for dysrhythmias and report and treat them immediately.
A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
Elevated protein An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include increased protein in the cerebrospinal fluid.
A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply).
Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water Allowing the bag to become too full can cause leakage. The client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. The client should avoid moisturizing soaps because lubricants can affect adhesion of the appliance.
A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4hr ago. Which of the following actions should the nurse take?
Encourage the client to perform dorisflexion of the affected extremity every 2 hr. The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
A nurse is caring for a client whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?
Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.
A nurse is caring for client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome?
Facial edema Superior vena cava syndrome is a medical emergency resulting from a partial occlusion of the superior vena cava, leading to a decreased blood flow through the vein. Most cases of superior vena cava syndrome are associated with cancers involving the client's upper chest (e.g., advanced lung and breast cancers and lymphoma). The earliest manifestations of superior vena cava syndrome are facial and upper extremity edema. Death can result if the compression is not corrected.
A nurse in the emergency department is assessing a client who was in a motor vehicle crash 2 days ago and sustained fracture of his tibia, ulna, and several ribs. The client is not disoriented to time and place and has SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect?
Fat embolism syndrome The nurse should identify the triad of neurological changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and a fracture of a long bone. Male clients are also at greater risk. The manifestations occur when far globules occlude small blood vessels.
A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect?
Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma the body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.
A nurse is caring for client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? (Select all that apply).
Flush the line with sterile 0.9% sodium chloride before and after medication administration Access the PICC for blood sampling Perform a heparin flush of the line at least daily when not in use The nurse should flush the line 10mL of sterile 0.9% sodium chloride solution before and after administering medication through the PICC. The nurse should use a PICC to deliver fluids, medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood samples, and the nurse should practice the appropriate technique to access and flush the line. Ideally, blood samples should come from a 4 French lumen catheter or larger.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?
History of asthma A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.
A nurse in the emergency department is caring for a client who has Addison's disease and reports nausea, vomiting, diarrhea, and abdominal pain. To prevent an Addisonian crisis, the nurse should prepare to administer which of the following medications?
Hydrocortisone Addison's disease causes adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency is life-threatening and can lead to severe fluid and electrolyte imbalances. Without treatment, sodium levels fall, and potassium levels increase. Rapid infusion of IV fluids such as 0.9% sodium chloride and IV administer of high dose corticosteroids such as hydrocortisone are vital to correct the glucocorticoid deficiency.
A nurse is caring for a client with Addison's disease who has been admitted with muscle weakness, dehydration, and nausea and vomiting for the past 2 days. Which of the following prescribed medications should the nurse plan to administer?
Hydrocortisone The nurse should identify that a client who has Addison's disease will require hydrocortisone to assist with replacing cortisol levels. A client who has Addison's disease has adrenal corticoid insufficiency, which is the inability of the pituitary to produce cortisol. Illness and stress can require steroids like hydrocortisone to restore hormone levels.
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?
Increase the oxygen flow and request an arterial blood gas determination. The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.
A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (Select all that apply)
Increased breast density BMI of 32 Undergoing hormonal replacement therapy for 10 years Women who have dense breast tissue are at an increased risk for developing breast cancer because they have more connective and glandular breast tissue. Postmenopausal obesity increases the risk for developing breast cancer. Hormone-related risks for developing breast cancer include the long-term use of oral contraceptives or hormone replacement therapy, early menarche, late menopause, and first pregnancy after 30 years of age.
A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?
Increased coughing The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing.
A nurse is teaching a client with systemic erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?
Infection The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a sore throat. Prednisone can suppress the client's immune response and mask the manifestations of an infection.
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?
Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect?
Involuntary muscle spasms The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency.
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the client's urinary drainage bag over 1 hour. Which of the following should the nurse take?
Irrigate the indwelling urinary catheter with a syringe. No drainage in the urinary drainage bag indicates an obstruction. The nurse should gently irrigate the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and irrigating fluid to drain.
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first?
Keep the client NPO The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk for dysphagia, which increases the change of life-threatening aspiration.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?
Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction?
Low back pain Low back pain is a manifestation of hemolytic transfusion reaction. Other manifestations include a headache, chest pain, tachypnea, tachycardia, and dark urine.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
Lower back discomfort An abdominal aortic aneurysm involves widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
A nurse is an acute care facility is preparing to admit a client who myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?
Oral-nasal suction equipment A client who has myasthenia gravis is at risk for aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.
A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet?
Orange and tomatoes Symptoms of GERD worsen following the oral intake of substances that decrease lower esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint.
A nurse in a provider's office is assessing a client's skin lesion. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions?
Papules A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.
A nurse is caring for a client who has urolithiasis and requires further diagnostic testing after an initial test indicated hypercalcemia. Which of the following structures controls calcium concentration?
Parathyroid gland The parathyroid gland secretes parathyroid hormones, which are substances that help the kidneys reabsorb calcium and increase calcium absorption from the gastrointestinal tract.
A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the nurse monitor?
Polyuria Diabetes insipidus is characterized by increased thirst (polydipsia) and increased urination (polyuria). A client who has diabetes insipidus will excrete large quantities of urine with a very low specific gravity.
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?
Position the client supine with his legs elevated when in bed. The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.
A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take?
Postpone any teaching with the client at this time The nurse should postpone any teaching with the client this time and should encourage the client to look at and touch the stoma before continuing to teach about self-care. Refusal to look at the stoma indicates the client is in the denial stage of grief and might not be able to learn anything further at this time about self-care of the colostomy.
A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values?
Potassium and magnesium Clients who have chronic kidney disease have hyperkalemia, hyperphosphatemia, and hypermagnesemia as well as elevations in serum creatinine and blood urea nitrogen.
A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take?
Prepare for replacement of the missing clotting factor. Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factors replacement is initiated to prevent hemoarthrosis, which can result in a long-term loss of range of motion in repeatedly affected joints.
A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse asses the client?
Progressive circular rash Early Lyme disease is characterized by a fever, influenza-like manifestations, and erythema migrans, which is distinct, progressive, circular or bullseye rash that often develops at the bite site but can also develop at other sites such as the thighs and knees.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?
Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.
A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommend restricting the intake of which of the following nutrients?
Protein Dietary restrictions for clients who have chronic kidney disease vary based on the degree of kidney function; however, most clients need protein limitations. Predialysis protein restriction can help preserve some kidney function.
A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications?
Respiratory obstruction Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.
A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis?
Rheumatoid factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.
A nurse is caring for client who is postoperative following a frontal craniotomy. The nurse should place the client in which if the following positions?
Semi-fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.
A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include?
Set an alarm to ensure medication dosages are taken on time The nurse should instruct the client to take medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
Sodium 132 mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. The normal sodium level is 135-145 mEq/L
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI?
Specific gravity Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.
A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBC's). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction.
Sudden oliguria The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBC's.
A nurse is performing assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to asses for changes in the client's abdominal distention?
Take serial measurements of the abdomen with a tape measure. Measuring the abdomen is the most-effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes.
An nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?
Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
A nurse is caring for client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect?
Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes. The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of the pacemaker.
A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client?
The client is unable to understand words or sentences they hear have receptive aphasia.
A nurse is caring for client who has a traumatic brain injury and assumes a decerebate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?
The client rigidly extends his arms A client who exhibits a decerebrate extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.
A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer?
The client uses tobacco.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires interventions?
The head of the bed is elevated to 20 degrees. The head of the bed should be elevated to at least 30 degrees (semi-Fowler's position) while the tube feeding is administered. This position gravity to help the feeding move through the digestive system an lessens the possibility of regurgitation.
A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?
Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch.
A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBC's?
Tissue hypoxia In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBC's) in the bone marrow.
A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) with mild manifestations. The nurse should expect the provider to prescribe which of the following medications?
Tolvaptan SIADH is a disorder of water intoxication due to the inappropriate continuous secretion of antidiuretic hormone by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH includes fluid restriction, sodium replacement with small amounts of 0.9 % sodium chloride, and a vasopressin antagonist such as tolvaptan. Tolvaptan promotes the excretion of water, which helps correct the fluid imbalance in clients who have SIADH.
A nurse is providing discharge instructions to a client who is postoperative following surgical excision of basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy?
Ulceration Ulceration, bleeding and exudation are indications of mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluation and the proper techniques for self-examination of the skin every month.
An older adult is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?
Urine Specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.
A nurse is caring for a client who has a stage III pressure injury. Which if the following findings contribute to delayed wound healing?
Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?
Use a 30-mL syringe The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide?
Use gravies or sauces to soften food The nurse should instruct the client to use gravies or sauces to soften foods and make them easier to eat.
A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take?
Warm the dialysate solution prior to administration The nurse should warm the dialysate solution prior to administration to prevent pain and abdominal cramping.
A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet?
White bread and plain yogurt Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber. The client can consume low-fiber foods like white bread, low-fat milk, yogurt with active cultures, poached eggs and canned soft fruit.
