Med-Surg Question Bank

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A client has an odorous, purulent wound. How does the nurse best support this client? Select one: a. Places room deodorizers in the room b. Changes the dressing frequently c. Encourages a diet high in protein d. Suggests whirlpool therapy

Frequent dressing changes help the client feel clean. A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family. The correct answer is: Changes the dressing frequently

The rare electrolyte disturbance that occurs primarily in the presence of renal failure is Select one: a. hypercalcemia. b. hypermagnesemia. c. hypernatremia. d. hyperchloremia.

Hypermagnesemia, with a serum level higher than 2.1 mEq/L, occurs rarely and primarily in the presence of renal failure. Hypermagnesemia can also occur in patients who have received too much magnesium, such as an intrapartum patient receiving a bolus of magnesium sulfate to treat worsening preeclampsia. The correct answer is: hypermagnesemia.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin? Select one: a. Ashen, gray, or dull b. Ruddy blue c. Patchy areas of pallor d. Generalized pallor

Pallor due to shock (decreased perfusion and vasoconstriction) in black-skinned people will cause the skin to appear ashen, gray, or dull. See Table 12-2. The correct answer is: Ashen, gray, or dull

When assessing a patient with scleroderma, which changes in the skin will be observed? Select one: a. Necrosis b. Hyperpigmented c. Hardening d. Thinning

Scleroderma is manifested by hardening of the skin. The correct answer is: Hardening

The nurse is instructing a client on skin and sun protection. Which statement by the client indicates a need for further teaching? Select one: a. "I am better protected from the sun because I am dark skinned." b. "I use a tanning bed to avoid the sun's harmful rays." c. "Sunscreen should be applied liberally." d. "My sunglasses are UVA and UVB protected."

Tanning beds are just as damaging to the skin as the sun's rays; the client stating that he or she uses a tanning bed indicates that the client needs further teaching. Dark-skinned people are better protected from the sun than light-skinned people. Regular use of sunscreen helps protect skin from the sun. Sunglasses with UVA- and UVB-protected lenses help shield the eyes from the sun's harmful rays. The correct answer is: "I use a tanning bed to avoid the sun's harmful rays."

An older immobile client has "sunk" to the bottom of the bed. What does the nurse do first? Select one: a. Gently pull the client up. b. Get help and lift the client. c. Pad the bony prominences. d. Look for broken skin areas.

The client should be gently lifted with a sheet. Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority. The correct answer is: Get help and lift the client.

The nurse is caring for an elderly patient with fluid-volume deficit. When prioritizing the plan of care for this patient, the nurse first Select one: a. weighs the patient. b. monitors intake and output. c. monitors vital signs. d. ensures safety.

The patient may become confused because of fluid and electrolyte losses. The correct answer is: ensures safety.

A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours PRN. The first assessment by the nurse should be to: Select one: a. assess pupillary reaction. b. see when the patient last received pain medication. c. assess for the presence of bowel sounds. d. ask the patient's family if she is having pain.

Verifying the time of the last dose decreases the risk of a dose of medication being given too soon. The correct answer is: see when the patient last received pain medication.

The nurse just received the a.m. shift report. Which client should the nurse assess first? a.The client diagnosed with coronary artery disease who has a BP of 170/100 mmHg b.The client diagnosed with deep vein thrombosis who complains of chest pain c.The client diagnosed with pneumonia who has a pulse oximeter reading of 95% d.The client diagnosed with ulcerative colitis who has diarrhea

b.The client diagnosed with deep vein thrombosis who complains of chest pain Chest pain is indicative of possible heart failure which takes priority. All other choices aren't emergent

A nurse assesses a client who has open lesions. Which action should the nurse take first? Select one: a. Assess the client's pain. b. Initiate standard precautions. c. Obtain vital signs. d. Assess for signs of infection.

Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on. The correct answer is: Initiate standard precautions.

The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?

800 u/hr

A 13-year old girl is interested in obtaining information about the cause of her acne. The nurse would share with her that acne: Select one: a. has no known cause. b. is caused by a poor diet. c. is contagious. d. has been found to be related to poor hygiene.

About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, a contagion, or poor hygiene. The correct answer is: has no known cause.

A nurse is triaging clients in the emergency department. Which client should the nurse classify as "nonurgent?" Select one: a. A 62-year-old with a simple fracture of the left arm b. A 50-year-old with chest trauma and absent breath sounds c. A 44-year-old with chest pain and diaphoresis d. A 79-year-old with a temperature of 104° F

A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The correct answer is: A 62-year-old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client should be considered "urgent"? Select one: a. A 20-year-old female with a chest stab wound and tachycardia b. A 50-year-old male with new-onset confusion and slurred speech c. A 75-year-old female with a cough and a temperature of 102° F d. A 45-year-old homeless man with a skin rash and sore throat

A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent. The correct answer is: A 75-year-old female with a cough and a temperature of 102° F

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? Select one: a. Transfer the client to a negative-pressure room. b. Apply oxygen via nasal cannula. c. Obtain a sputum culture and sensitivity. d. Administer intravenous 0.9% saline solution.

A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The correct answer is: Transfer the client to a negative-pressure room.

A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? Select one: a. "Being able to sleep doesn't mean pain doesn't exist." b. "The client should be assessed for drug addiction." c. "You're right; I would put the medication back." d. "Have you ever experienced any type of pain?"

A client's description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose. The correct answer is: "Being able to sleep doesn't mean pain doesn't exist."

A patient drank a cup of coffee, a half cup of orange juice, and ½ pint of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed Select one: a. 400 mL. b. 600 mL. c. 360 mL. d. 480 mL.

A coffee cup is generally equivalent to 240 mL, whereas a half cup of juice is 120 mL, and because an ounce is generally equal to 30 mL, the nurse would add an additional 240 mL (the milk), which gives a total of 600 mL. The correct answer is: 600 mL.

A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best? Select one: a. Ask the client why he or she is being uncooperative with therapy. b. Tell the client that physical therapy is required to regain function. c. Increase the dose of analgesia given prior to therapy sessions. d. Ask the client about pain goals and if they are being met.

A comprehensive pain management plan includes the client's goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the client's pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the client's behavior. Asking the client why he or she is being uncooperative is not the best response for two reasons. First, "why" questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the client that physical therapy is required does not address the issue. The correct answer is: Ask the client about pain goals and if they are being met.

The nurse is measuring postural vital signs for a patient who has been diagnosed with dehydration. The pulse rate increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure to show a(n) Select one: a. drop of 40 mm Hg. b. increase of 10 mm Hg. c. increase of 5 mm Hg. d. drop of 20 mm Hg.

A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate increase of at least 10 beats/min at 1 minute following position change is suggestive of fluid-volume deficit. The correct answer is: drop of 20 mm Hg.

Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? Select one: a. Presence of one of the "ABCDE" features b. Dark red color c. 1-mm ecchymotic area on the upper extremity d. Round and raised appearance

A lesion with one or more of the ABCDE features (asymmetry, border irregularity, color variation, diameter, evolving features) should be evaluated by a dermatologist or a surgeon. Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic. The correct answer is: Presence of one of the "ABCDE" features

The nurse has been caring for a patient in the perioperative area for several hours. The surgical mask the nurse is wearing has become moist. The nurse's best next step is to Select one: a. Not change the mask, if the nurse is comfortable. b. Change the mask when relieved. c. Air-dry the mask while at lunch, and reapply. d. Ask for relief, step out of the surgical area, and apply a new mask.

A mask should fit snugly around the face and nose. After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture encourages the growth of microorganisms. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control. The correct answer is: Ask for relief, step out of the surgical area, and apply a new mask.

A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site? Select one: a. Right hand b. Left hand c. Left upper forearm d. Right upper forearm

A new IV site should not be placed distal to an old site; the right hand is distal to the right forearm, so it should not be used. The correct answer is: Right hand

To prevent injury to a patient before administering preoperative medication, the best action for the nurse is to Select one: a. have the patient remove a hearing aid. b. have the patient void in the bathroom. c. teach postoperative leg exercises. d. send personal belongings home with family.

A patient should void in the bathroom and get on the stretcher before being premedicated for surgery, which reduces the risk of falls by eliminating the need to use the bathroom once sedative medication has been given. The correct answer is: have the patient void in the bathroom.

The client is to have a surgical procedure under (moderate) conscious sedation. The client is anxious and asks the nurse what to expect. What is the nurse's best response? Select one: a. "You will not be able to move your feet or toes during the procedure." b. "You will not be able to swallow or talk during the procedure." c. "You will be awake and alert during the procedure but you will feel no pain." d. "You will be very sleepy and we will monitor you closely."

A physician or a specially credentialed registered nurse may administer agents for conscious sedation. This rapid and short-acting type of anesthesia, used for brief but uncomfortable procedures, does not render the client completely unconscious. Clients have a reduction in intensity or awareness of the pain without loss of defensive reflexes. The correct answer is: "You will be very sleepy and we will monitor you closely."

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. Which action is the most appropriate to take? Select one: a. Tell him it must be removed, and send it to the hospital safe for storage. b. Tell him it must be removed, and leave it in a cup in the bedside stand. c. Ask a family member to bring it home for just 1 day. d. Tape it in place on his finger.

A wedding band may be worn to surgery, but it must be taped to the finger in a manner that does not restrict circulation. The correct answer is: Tape it in place on his finger.

A patient has been identified as having a deficiency of vitamin D. The nurse understands that this patient is at risk for having a deficiency of what electrolyte? Select one: a. Calcium b. Potassium c. Magnesium d. Sodium

A. Nutritional deficiency of calcium or vitamin D can result in hypocalcemia. The correct answer is: Calcium

The nurse is developing the interventions for a client with pneumonia and ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important to include? a. Increase fluid intake to 3000 ml/day b. Administer O2 at 2 L/minute per nasal cannula c. Maintain the client in a semi-Fowler position d. Provide chest percussion while lying supine

A. increase fluid intake to 3000 ml/day couldn't find rationale

The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the client's abdomen and notes that there are no bowel sounds. What action does the nurse take? Select one: a. Palpate the bladder and measure abdominal girth. b. Document the finding and continue to monitor. c. Position the client on the left side with the bed flat. d. Insert a nasogastric tube to low intermittent suction.

Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time. The correct answer is: Document the finding and continue to monitor.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? Select one: a. Consistent use of Standard Precautions b. Wearing a mask within 3 feet of the client c. Double-gloving before body fluid exposure d. Labeling charts and armbands "HIV+"

According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact. The correct answer is: Consistent use of Standard Precautions

Before the nurse brings the client to the operating room (OR) for knee surgery, the client reports to the nurse that he did not mark the operative knee with the surgeon. What is the priority action of the nurse? Select one: a. Call a "time out" so the site can be marked before surgery begins. b. Call the surgeon to mark the site with the client before transfer to the OR. c. Proceed with transferring the client to the OR as planned. d. Have the client mark the site before transfer to the OR.

According to The Joint Commission, the surgical site should be marked by both the client and the surgeon before anesthesia is administered and surgery begins when the surgery involves a specific side. The correct answer is: Call the surgeon to mark the site with the client before transfer to the OR.

A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? Select one: a. Administer pain medication and then proceed with the assessment. b. Complete the physical examination first and then give the pain medication. c. Tell the patient that the pain medication must wait until after the x-rays are completed. d. Evaluate full range of motion of the knee and then medicate for pain.

According to the American Pain Society (1992), "In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures." The correct answer is: Administer pain medication and then proceed with the assessment.

Information essential for the nurse to gather when interviewing a young woman who is taking the drug Accutane (isotretinoin) for acne is which of the following? Select one: a. Current method of birth control b. Drugs previously used c. Usual weight d. Family history of breast cancer

Accutane can cause severe fetal deformities. The correct answer is: Current method of birth control

A 12-year-old female visits her primary care provider to obtain acne medication for recurrent acne vulgaris. This condition is an inflammatory disorder of the: Select one: a. Eccrine gland b. Dermal layer c. Apocrine glands d. Pilosebaceous follicle

Acne vulgaris is an inflammatory disorder of the pilosebaceous follicle.Acne vulgaris is an inflammatory disorder of the pilosebaceous follicle, not the apocrine glands.Acne vulgaris is an inflammatory disorder of the pilosebaceous follicle, not the dermal layer.Acne vulgaris is an inflammatory disorder of the pilosebaceous follicle, not the eccrine gland. The correct answer is: Pilosebaceous follicle

Which patient will develop active immunity? A patient who: Select one: a. Has T cells that become B cells b. Receives preformed antibodies or T cells from a donor c. Receives immunoglobulin d. Has natural exposure to an antigen or receives an immunization

Active immunity occurs after either natural exposure to an antigen or after immunization.Active immunity occurs after either natural exposure to an antigen or after immunization, not with preformed antibodies.Active immunity occurs after either natural exposure to an antigen or after immunization, not when T cells become B cells.Active immunity occurs after either natural exposure to an antigen or after immunization, not when the patient receives immunoglobulins. The correct answer is: Has natural exposure to an antigen or receives an immunization

When evaluating a patient's pain, the nurse knows that an example of acute pain would be: Select one: a. fibromyalgia. b. arthritic pain. c. kidney stones. d. low back pain.

Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain where the pain continues for 6 months or longer and does not stop when the injury heals. The correct answer is: kidney stones.

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? Select one: a. Administration of immunosuppressant medications b. A blood draw for human leukocyte antigen (HLA) matching c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. The correct answer is: Administration of immunosuppressant medications

The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery. The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases. What is the nurse's priority action? Select one: a. Call a code or the Rapid Response Team. b. Turn the client and perform chest physiotherapy. c. Prepare to administer naloxone (Narcan). d. Assess oxygen saturation and level of consciousness

Additional data are needed to determine respiratory status, so the nurse must finish the assessment with an oxygen saturation (SaO2) and check the client's level of consciousness. A respiratory rate of less than 10 could indicate an emergency, especially if the SaO2 drops below 95%. A respiratory rate of less than 10 breaths/min may indicate anesthetic-induced depression. Naloxone should not be administered unless there are clear indications for it, and performing chest physiotherapy may not be warranted. Calling a code or the Rapid Response Team may be needed, but only after a complete assessment. The correct answer is: Assess oxygen saturation and level of consciousness.

For the osteoporotic patient on alendronate (Fosamax), the nurse would stress that the drug requires that the patient should: Select one: a. sit or stand for 30 minutes following administration. b. take the drug after breakfast. c. decrease fluid intake. d. avoid use of supplemental vitamin D.

After taking the drug Fosamax with 8 ounces of fluid, the patient should sit or stand for 30 minutes so that the drug will be evenly distributed. The drug is taken on an empty stomach. The correct answer is: sit or stand for 30 minutes following administration.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment? Select one: a. Wong-Baker FACES Pain Scale b. FACES Pain Scale-Revised c. Verbal Descriptor Scale d. Numeric rating scale

All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. The correct answer is: FACES Pain Scale-Revised

The RN is monitoring a nurse student who performs care of a PICC line. The nurse observes the student doing all of the following activities. Which activity indicates the need for further education? Select one: a. Using sterile gloves to change the line dressing b. Cleaning the needleless injection cap with alcohol before accesing c. Cleaning the catheter with movements away the site of insertion d. Flushing the line with3 mL syringe

All catheteres should be flushed with syringes with barrels of 10 mL or larger. The smaller the barrel, the greater the pressure that comes from the tip. Smaller syringes could damage the catheter.The rest of interventions were correct. The correct answer is: Flushing the line with3 mL syringe

A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client? Select one: a. "Check any over-the-counter medications for acetaminophen." b. "Keep your follow-up appointment with the surgeon as scheduled." c. "Eat more fiber and drink more water to prevent constipation." d. "Call the doctor if the Lorcet does not relieve your pain."

All instructions are appropriate for this client. However, advising the client to check over-the-counter medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day. The correct answer is: "Check any over-the-counter medications for acetaminophen."

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? Select one: a. Autoimmune hemolytic anemia b. Allergic asthma c. Rheumatoid arthritis d. Poison ivy

Allergic asthma is a manifestation of type I hypersensitivity. Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity. The correct answer is: Allergic asthma

Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? Select one: a. "Reaction to the testing will take about 48 to 72 hours to occur." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Do not eat anything for about 6 hours before the testing."

Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. The correct answer is: "Plan to wait in the clinic for 20 to 30 minutes after the testing."

Twenty minutes after a client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse's priority action? Select one: a. Administer diphenhydramine (Benadryl). b. Explain to the client that these symptoms are expected. c. Document the findings. d. Assess the client's pulse and blood pressure.

Although these are expected physiologic responses to the preoperative medication, whenever the client states that he or she can feel a change in normal cardiac function, he should be assessed. The correct answer is: Assess the client's pulse and blood pressure.

The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, "I felt something 'give way' when I coughed." What is the nurse's best response? Select one: a. "Lie down flat on the bed with your knees up and let me examine your incision." b. "Be sure to splint the incision with a pillow or your hands when you cough." c. "That is a normal feeling in the incision whenever you are moving." d. "It is good that you are coughing and deep-breathing to prevent pneumonia."

Although wound dehiscence is not a common complication after surgery, it is usually painless and the client feels as if something has split or given way. This frequently occurs after coughing. Any client report of such a sensation should be assessed immediately. The correct answer is: "Lie down flat on the bed with your knees up and let me examine your incision."

The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? Select one: a. Paraplejic adult client with stage I pressure ulcers who needs to be turned every 2 hours b. Seventeen-year old client who needs to be admitted in the outpatient surgery unit for extirpation of a sebaceous cyst c. Adult female who is going to be discharged home after receiving steroids for Stevens-Johnson syndrome d. Adult client who has a stage 3 pressure ulcer infected with vancomycin resistant enterococcus (VRE)

An LPN/LVN would be familiar with wound monitoring and cure of potentially contaminated wounds and would recognize the manifestations of infection, and infection control. Conducting an admission assessment and discharge teaching are more complex nursing actions that require RN-level education and scope of practice. The paralized adult with stage I pressure ulcers who needs to be turned every 2 hours could be cared for by a nursing assistant. The correct answer is: Adult client who has a stage 3 pressure ulcer infected with vancomycin resistant enterococcus (VRE)

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents' health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing? Select one: a. The obstetrician b. Her parents c. Her husband d. The patient

An emancipated minor (married or independently earning his or her own living) may sign his or her own consent form. In this case, the patient is the only person who can provide consent unless she would be neurologically incapacitated or incompetent, in which case her husband would need to provide consent. The correct answer is: The patient

A client who is human immune deficiency virus (HIV) positive and has a CD4+ count of 15 has just been admitted with a fever and abdominal pain. Which health care provider request does the nurse implement first? Select one: a. Call for a portable chest x-ray. b. Obtain a 12-lead electrocardiogram (ECG). c. Give cefazolin (Kefzol) 500 mg IV. d. Obtain blood cultures from two sites.

Antibiotics should be given as soon as possible to immunocompromised clients, but blood cultures must be obtained first so that culture results will not be affected by the antibiotic. A 12-lead ECG can be obtained and calling for a portable chest x-ray can be done after other priority requests have been carried out. The correct answer is: Obtain blood cultures from two sites.

An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to Select one: a. breathe fast through his nares. b. sit up. c. lie down. d. breathe through a rebreather mask

Anxiety can lead to hyperventilation, causing respiratory alkalosis, and the treatment is to have the patient breathe through a rebreather mask. In the home setting, the patient can be asked to breathe into a paper bag. The correct answer is: breathe through a rebreather mask.

When assessing the intensity of a patient's pain, which question by the nurse is appropriate? Select one: a. "What makes your pain better or worse?" b. "How does pain limit your activities?" c. "What does your pain feel like?" d. "How much pain do you have now?"

Asking the patient "how much pain do you have?" is an assessment of the intensity of a patient's pain; various intensity scales can be used. Asking what makes one's pain better or worse assesses alleviating or aggravating factors. Asking if pain limits one's activities assesses the degree of impairment and quality of life. Asking "what does your pain feel like" assesses the quality of pain. The correct answer is: "How much pain do you have now?"

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Select one: a. Keep a normal weight b. Eat at least 2 cups of yogurt per day. c. Take up knitting to slow down joint degeneration. d. Begin a running program.

Avoiding excessive weight will help prevent damage to weight supporting joints, especially knees and hips. Running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet is recommended. The correct answer is: Keep a normal weight

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? A. Notify the healthcare provider for reinsertion. B. Attempt to reinsert the tracheostomy tube. C. Position the client in a lateral position with the neck extended. D. Ventilate client's tracheostomy stoma with a manual bag-mask.

B) Attempt to reinsert the tracheostomy tube. The nurse should attempt to reinsert the tracheostomy tube (B) by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed. (A, C, and D) place the client at risk of airway obstruction.

The nurse is assessing the client with COPD. Which data require immediate intervention by the nurse? a.Large amounts of thick white sputum b.Oxygen flowmeter set on six liters c.Use of accessory muscles during inspirations d.Presence of a barrel chest and dyspnea

B. Oxygen flow meter set on six liters A. a large amount of thick sputum is a common symptom of COPD. B. nurse should decrease the oxygen rate. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases, the drive to breathe may be eliminated. Careful monitoring is important to prevent complications. C. common for clients with COPD to use accessory muscles to inhale. The clients tend to lean forward D. In COPD, there is a characteristic of barrel chest from chronic hyperinflation, and dyspnea is common

The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? Select one: a. "Every morning, I check the biopsy site for signs of infection." b. "I will increase fruits and vegetables of all colors." c. "I will exercise working in my garden between 9 am to 3 pm." d. "I will wear solar protective lotion before leaving home."

Basal cell carcinomas of the skin are associated with sun exposure. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens. The client should check the biopsy site daily for signs of infection. Using solar protection and increasing the ingestion of vegetables and fruits is healthy. Sunlight should be avoided, mainly between 9 am to 3 pm. The correct answer is: "I will exercise working in my garden between 9 am to 3 pm."

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

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

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information? Select one: a. Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias. b. Instruct the patient to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. c. Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. d. Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the patient that these supplements have minimal effect on the surgical procedure.

Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided. The correct answer is: Instruct the patient to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

The female client in the preoperative holding area tells the nurse that she had areaction to a latex diaphragm. Which intervention should the nurse perform first? Select one: a. Notify the operating room personnel. b. Inform the client to tell all HCPs of the allergy. c. Place a red allergy band on the client. d. Label the client's chart with the allergy.

Because the client is in the preoperative holding area, the immediate safety need for the client is to inform the operating room personnel so that no latex gloves or equipment will come into contact with the client. Person-to-person communication for a safety issue ensures that the information is not overlooked. The correct answer is: Notify the operating room personnel.

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? Select one: a. Change the settings based on range of motion. b. Assess the distal circulation in 30 minutes. c. Remind the client to do quad-setting exercises. d. Raise the lower siderail on the affected side.

Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's 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 correct answer is: Raise the lower siderail on the affected side.

The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety? Select one: a. Administer 5 mL of a heparinized solution. b. Check for blood return. c. Flush the port with 10 mL of normal saline. d. Palpate the port for stability.

Before a drug is given through an implanted port, it is critical that the nurse check for blood return. If no blood return is observed, the drug should be held until patency is reestablished. Ports are flushed with heparin or saline after, rather than before, use. The port is palpated for stability, but this action alone does not ensure the client's safety. The correct answer is: Check for blood return.

The nurse performs Allen's test before obtaining an ABG specimen to determine Select one: a. the patency of the radial artery. b. the presence of neuromuscular weakness. c. if an allergy to heparin is present. d. if ulnar arterial circulation is adequate

Before radial puncture to obtain ABG specimens, Allen's test should be performed to ascertain adequate ulnar circulation. Failure to assess ulnar circulation could result in ischemic injury to the client's hand. The correct answer is: if ulnar arterial circulation is adequate.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? Select one: a. A 26-year-old who is bedridden with a fractured leg b. A 44-year-old prescribed IV antibiotics for pneumonia c. A 78-year-old, post-stroke, requiring assistance to ambulate with a walker d. A 32-year-old with paraplejia and incontinence

Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client recovering from a stroke who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 32-year-old the person at highest risk. The correct answer is: A 32-year-old with paraplejia and incontinence

An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling? Select one: a. Pulse rate of 62 beats/min and bounding b. Orthostatic blood pressure changes c. Dry oral mucous membranes d. Serum potassium level of 3.4 mEq/L

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

The nurse is caring for an older adult client with a history of chronic lung disease who will be undergoing surgery the following day. When postoperative care is planned, which potential problem is the highest priority for this client? Select one: a. Tolerating activity b. Maintaining oxygenation c. Hypovolemia d. Anxiety and fear

Breathing problems take priority over the other problems listed. This would be compounded in a client with any chronic lung disorder. The correct answer is: Maintaining oxygenation

The home health nurse conducts a community presentation on Lyme disease for the residents of an assisted-living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? Select one: a. "It is best to walk in the center of the trail." b. "I'll wear light-colored clothes with long sleeves, long pants, closed shoes, and a hat when I am walking in the woods." c. "I will gently remove the tick and then burn it to prevent the spread of the disease." d. "I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease."

Burning a Lyme disease-carrying tick could spread infection, so flushing it down the toilet is the recommended disposal method; this statement indicates that further instruction is needed. Walking in the center of the trail is a protective measure against Lyme disease. If bitten, testing is not reliable until 4 to 6 weeks later. Wearing light-colored clothes, long pants, long sleeves, closed shoes, and hat are appropriate skin protection measures against Lyme disease. The correct answer is: "I will gently remove the tick and then burn it to prevent the spread of the disease."

While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? Select one: a. Assign the client to a private room with a negative airflow. b. Wear a mask when working within 3 feet of the client. c. Wear a gown and gloves to prevent contact with the client or client-contaminated items. d. Have the client wear a surgical mask when being transported out of the room.

Caregivers should wear a gown to prevent contact with the client or contaminated items when caring for a client with this infection; this is the best way to prevent the spread of infection. Gloves should also be worn when entering the room. The client does not require respiratory isolation and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection. The correct answer is: Wear a gown and gloves to prevent contact with the client or client-contaminated items.

While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? Select one: a. Have the client wear a surgical mask when being transported out of the room. b. Wear a mask when working within 3 feet of the client. c. Wear a gown and gloves to prevent contact with the client or contaminated items. d. Assign the client to a private room with a negative airflow.

The patient with HIV complains to the home health nurse that he has been having watery diarrhea for the last 10 days. Because the nurse suspects toxoplasmosis, a significant question for the nurse to ask would be: Select one: a. "Have you been drinking alcohol?" b. "Do you have a cat?" c. "Have you stopped taking your antiviral medication?" d. "Have you been eating aged cheese or organ meats?"

Cat litter boxes and undercooked meats are the major sources of toxoplasmosis, which causes a persistent watery diarrhea. The correct answer is: "Do you have a cat?"

A nurse assesses an older client who has multiple purpuric discolorations only on the skin of both forearms. Which question should the nurse ask first? Select one: a. "Do you have a pet at home?" b. "What medications are you taking?" c. "Are you exposing your arms to sunlight?" d. "Is someone at home physically abusing you?"

Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising. Abuse related bruisings are generally found in body areas covered by clothes. The correct answer is: "What medications are you taking?"

The nurse explains that the painful shingles experienced by the patient with HIV is related to his childhood exposure to: Select one: a. Impetigo b. Chickenpox x c. Mumps d. Measles

Chickenpox can be reactivated as shingles. The correct answer is: Chickenpox

Which patient is at risk for compartment syndrome due to a burn?* Select one: a. A 7 year old with a burn of the left and right ear. b. A 25 year old with circumferential burn of the anterior and posterior left arm. c. A 55 year old with an electrical burn on the neck. d. A 15 year old with a chemical burn to the right foot.

Circumferential burns of the extremities produce a tourniquet like effect and leads to vascular problems. The correct answer is: A 25 year old with circumferential burn of the anterior and posterior left arm.

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? Select one: a. Consult a dietitian. b. Utilize hydrogel dressing. c. Irrigate with hydrogen peroxide. d. Use a low-air-loss therapy unit.

Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate. The correct answer is: Irrigate with hydrogen peroxide.

Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate? Select one: a. Transfer the client to the intensive care unit (ICU). b. Call a code or the Rapid Response Team. c. Accompany the client to the postanesthesia care unit (PACU). d. Keep the client in the surgical suite.

Clients in critical condition are transferred from the operating room directly to the ICU. This client is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal. The correct answer is: Transfer the client to the intensive care unit (ICU).

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? Select one: a. "I must carry two EpiPens with me at all times." b. "I don't need to go to the hospital after using it." c. "This can be injected right through my clothes." d. "I will write the expiration date on my calendar."

Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment. The correct answer is: "I don't need to go to the hospital after using it."

The nurse is caring for several clients on the postoperative unit. Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia? Select one: a. Young adult with a body mass index of 40 b. Older woman taking a calcium channel blocker for hypertension c. Middle-aged man with a deviated nasal septum d. Middle-aged woman taking St. John's wort daily for depression

Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs fully. The other clients would not have an elevated risk of respiratory complications. The correct answer is: Young adult with a body mass index of 40

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? Select one: a. Large contusion to the forehead and a bloody nose b. Closed fracture of the right clavicle and arm numbness c. Multiple fractured ribs and shortness of breath d. Dislocated right hip and an open fracture of the right lower leg

Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent. The correct answer is: Multiple fractured ribs and shortness of breath

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? Select one: a. Wound inspection b. Creatinine kinase c. Electrocardiogram (ECG) d. Computed tomography of head

Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority. The correct answer is: Electrocardiogram (ECG)

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Select one: a. Abdominal bloating after eating b. Excessive production of saliva in the mouth c. Intermittent episodes of diarrhea d. Dry eyes

Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis sicca). Abdominal bloating, excessive saliva production, and diarrhea are not common conditions in clients with Sjögren's syndrome; however, dry mouth is commonly described. The correct answer is: Dry eyes

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Select one: a. Abdominal bloating after eating b. Excessive production of saliva with mouth pain c. Immune deficiency with frequent diarrhea d. Dry eyes

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism? Select one: a. Place the patient on Droplet Precautions. b. Teach the patient cough etiquette. c. Wear an N95 respirator when entering the patient room. d. Instruct assistive personnel to use soap and water rather than sanitizer to clean hands.

Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore Droplet Precautions are not needed. An N95 respirator is used primarily for patients with airborne illness. All patients should be taught cough etiquette; this action is not one to be take especially because the patient has Clostridium difficile. The correct answer is: Instruct assistive personnel to use soap and water rather than sanitizer to clean hands.

The nurse is reviewing the lab data of a newly admitted patient. The nurse notes the patient had an erythrocyte sedimentation done, and the results are quite elevated. The nurse would focus the care plan on which of the following conditions? Select one: a. Anemia b. Infection c. Inflammation d. Electrolyte imbalance

Common laboratory tests for inflammation measure levels of acute phase reactants. An increase in fibrinogen is associated with an increased erythrocyte sedimentation rate, which is considered a good indicator of an acute inflammatory response.Anemia would not result in an increased erythrocyte sedimentation rate.An infection would result in an increase in white blood cell count, but not the erythrocyte sedimentation rate.An electrolyte imbalance would not cause a rise in the sedimentation rate. The correct answer is: Inflammation

The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease? Select one: a. Wear a gown, gloves, face mask, and goggles for interactions with the patient. b. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. c. Transport the patient quickly when going to the radiology department. d. Place the patient in a room with negative airflow.

Contact Precautions are a type of Isolation Precaution used for patients with illness that can be transmitted through direct or indirect contact. A patient is placed on Contact Precautions if a disease is present that can be transmitted through direct or indirect contact. Patients who are on Contact Precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on Contact Precautions. A face mask and goggles are not part of Contact Precautions. A room with negative airflow is needed for patients placed on Airborne Precautions; it is not necessary for a patient on Contact Precautions. When a patient on Contact Precautions needs to be transported, he should wear clean gowns, and wheelchairs or gurneys should be covered with an extra layer of sheets. Anyone who might come in contact with the patient needs to be protected, and equipment must be cleaned with an approved germicide after patient use and before another patient uses the shared equipment. The correct answer is: Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? Select one: a. Report the need for desensitization therapy. b. Communicate the need for avoidance therapy to the health care team. c. Convey the need for pharmacologic therapy to the health care provider. d. Discuss symptomatic therapy with the health care provider.

Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins. Avoidance therapy is the recommended nursing intervention. Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Medications might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are effective only after the hypersensitivity reaction has already occurred. The correct answer is: Communicate the need for avoidance therapy to the health care team.

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first? Select one: a. Client with no bolus request in 6 hours b. Client who is pressing the button every 10 minutes c. Client who appears to be sleeping soundly d. Client with a respiratory rate of 8 breaths/min

Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain. The correct answer is: Client with a respiratory rate of 8 breaths/min

A patient has just undergone placement of a central venous catheter through the subclavian vein. Fluid infusions through the catheter cannot begin until placement is verified by Select one: a. length of catheter that was inserted. b. results of chest x-ray. c. quality of breath sounds. d. absence of heart murmurs.

Correct placement of subclavian catheters must be verified by radiographic studies before any fluid is infused through them. The correct answer is: results of chest x-ray.

The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to be extubated? Select one: a. Client who is coughing and gagging b. Client who is alert and oriented c. Client with an oxygen saturation of 90% d. Client with a respiratory rate of 14 breaths/min

Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation; the client should be further assessed to see whether he or she meets other extubation criteria. Often these criteria include ability to raise and hold the head up and evidence of thoracic breathing. An oxygen saturation of 90% is abnormal. Respiratory rate and orientation status are not sufficient criteria for extubation. The correct answer is: Client who is coughing and gagging

A nurse is instructing a patient who had surgical removal of a brain tumor on how to prevent respiratory complications from surgery. The best action to include in the teaching plan is Select one: a. turning, coughing, and deep breathing. b. using deep breathing and an incentive spirometer. c. turning gently from side to side. d. avoiding coughing and deep breathing.

Coughing may be contraindicated for patients who have had hernia repair, eye, ear, or brain surgery. This is because the act of coughing could create increased pressure in the surgical area, which is contraindicated. The correct answer is: using deep breathing and an incentive spirometer.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? A. Apply sequential compression devices (SCDs) bilaterally. B. Assess for a positive Homan's sign in each leg. C. Assess pulses on the affected leg. D. Advise the client to remain in bed and compare legs' circumferences

D. Advise the client to remain in bed and compare legs' circumferences The client is exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility. The initial care includes bedrest and elevation of the extremity.

The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? a.The client's pulse oximeter reading is 92% b.The client's pCO2 is 48 mmHg and HCO3 28 mEq/L c.The client has SOB when walking from bed to bathroom d.The client's sputum is rusty colored

D. the client's sputum is rusty colored 1. The client with end-stage COPD would have decreased peripheral oxygen levels; therefore, this would not warrant immediate intervention. 2. The client's ABGs would normally have a low oxygen level; therefore, this would not warrant immediate intervention. 3. The client would have shortness of breath (SOB) when ambulating to the bathroom. 4. Rusty-colored sputum may indicate blood in the sputum and would require further assessment by the nurse.

The nurse is caring for a postoperative patient. To best prevent deep vein thrombosis (DVT) in this patient, the nurse plans to diligently ensure that the patient: Select one: a. splints the incision. b. regularly removes antiembolism stockings. c. ambulates frequently. d. coughs and deep-breathes every 2 hours.

DVT is best prevented by early and frequent ambulation of the patient. The correct answer is: ambulates frequently.

As adults age, which common physiologic change is likely to alter their hydration status? Select one: a. Increased thirst mechanism b. Decreased muscle mass c. Poor skin turgor d. Increased capacity for renal concentration of urine

Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Kidneys have less capacity to concentrate urine in elders and for that reason waste water even if dehydrated. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status. The correct answer is: Decreased muscle mass

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? Select one: a. "The patient has developed acquired immunodeficiency syndrome (AIDS)." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient will develop symptomatic chronic HIV infection in less than a year." d. "The patient meets the criteria for a diagnosis of an acute HIV infection."

Development of PCP meets the diagnostic criterion for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection. The correct answer is: "The patient has developed acquired immunodeficiency syndrome (AIDS)."

The nurse in the dermatology service is teaching a female client about management of acne. Which statement by the client requires intervention Select one: a. I have to use two contraceptive methods while taking isotetroine b. I should avoid vitamine supplements when using isotetroine c. I would eliminate chocolate and butter from my diet in order to improve my acne d. I have to carefully wash my face several times per day with antiseptic soap

Diet has not influence in the evolution of acne The correct answer is: I would eliminate chocolate and butter from my diet in order to improve my acne

Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? Select one: a. "I told family members they need to wash their hands when they enter and leave the room." b. "Yes, I understand the reasons why I have to wear gloves when I bathe the client." c. "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client." d. "The client's spouse told me she got HIV from a blood transfusion."

Discussing this client's illness outside of the client's room is a breach of confidentiality and requires further education by the nurse. Instruction on handwashing to family members or friends is not a breach of confidentiality. Understanding the reasons for wearing gloves recognizes Standard Precautions in direct care and is not a breach of confidentiality. Relaying a direct conversation to the nurse is not a breach of confidentiality. The correct answer is: "The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client."

A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider? Select one: a. Self-reported pain of 3/10 b. Urine output of 20 mL/2 hr c. Bilateral lung crackles d. Hypoactive bowel sounds

Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the-clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it. The correct answer is: Urine output of 20 mL/2 hr

A 22-year-old-woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? Select one: a. Nonsteroidal anti-inflammatory drugs for pain b. Thyroid replacement hormone for hypothyroidism c. Tetracyclines for acne d. Proton pump inhibitors for heartburn

Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline. The correct answer is: Tetracyclines for acne

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes Select one: a. Irrigation of the wound. b. Débridement of the wound. c. Monitoring of the wound. d. Management of drainage.

Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean. The correct answer is: Débridement of the wound.

A patient with congestive heart failure has gained 1.1 pounds over the last 24 hours. After converting this number to kilograms of weight, the nurse further calculates that this patient has gained how much fluid weight? Select one: a. 0.5 L b. 1.0 L c. 2.0 L d. 0.25 L

Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of fluid. Therefore 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid. The correct answer is: 0.5 L

The patient and the nurse are discussing Rickettsia rickettsii-Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission of this disease? Select one: a. "When I go camping, I will be sure to use hand gel on my hands." b. "When I go camping, I will be sure to wear sunscreen." c. "When I go camping, I will be sure to wear insect repellent." d. "When I go camping, I will drink bottled water."

Each infectious disease has a specific mode of transmission-a component of the chain of infection. Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease. The correct answer is: "When I go camping, I will be sure to wear insect repellent."

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? Select one: a. Administer ordered diuretics b. Elevates the head of the bed c. Places the extremities in a dependent position d. Draws blood for laboratory tests

Elevating the head of the bed will ease breathing for the client, so it should be done first. Although drawing blood for laboratory tests may be indicated, the nurse should perform interventions that will help with physiologic changes caused by fluid overload first. Diuretics can be administrated after easing the patient's breathing capacity. The correct answer is: Elevates the head of the bed

A client has symptoms of systemic lupus erythematosus (SLE). Which laboratory finding indicates to the nurse that the client may have SLE? Select one: a. Erythrocyte sedimentation rate (ESR), 20 mm/hr b. A positive rheumatoid factor c. Positive total antinuclear antibody (ANA) d. Creatinine level of 1.2 mg/dL

Elevation of total ANA is common in systemic lupus erythematosus, systemic sclerosis, and RA. Rheumatoid factor is positive in rheumatoid arthritis. An ESR rate of less than 22 mm/hr is normal for a female. A creatinine level of 1.2 mg/dL is normal. The correct answer is: Positive total antinuclear antibody (ANA)

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled? Select one: a. Without delay because the bleed is emergent b. Within 24 hours c. As soon as all the day's elective surgeries have been completed d. Within the next week

Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed. The correct answer is: Without delay because the bleed is emergent

A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen. What is the immediate priority? Select one: a. Aggressive pain control b. Emergent surgery to control bleeding c. Assessment of neurologic status d. Calling the family members

Emergent surgery is indicated when the client may die without immediate intervention. Other interventions are appropriate but do not have the priority because controlling hemorrhage via surgery is the priority. The correct answer is: Emergent surgery to control bleeding

Biochemical secretions that trap and kill microorganisms include: Select one: a. Gastric acid b. Hormones c. Earwax d. Neurotransmitters

Epithelial cells secrete several substances that protect against infection, including earwax.Hormones do not contain biochemical secretions that trap and kill microorganisms.Neurotransmitters carry important messages, but they do not contain biochemical secretions.Gastric acid helps break down food into its component parts, but does not contain biochemical secretions. The correct answer is: Earwax

The patient has burns to both forearms that extend from the fingers to the elbows with no normal tissue present. The nurse has difficulty assessing the patient's pulse, and the patient complains of numbness in the fingers. The nurse notifies the primary care provider and expects the primary care provider to: Select one: a. Order physical therapy. b. Increase fluid intake. c. Perform an escharotomy. d. Perform debridement of some burned tissue.

Escharotomies (tissue decompression by cutting through burned skin) are performed to release pressure and prevent compartment syndrome (the compression of blood vessels, veins, muscle, or abdominal organs resulting in irreversible injury).The patient needs relief from the compression of the burns; increasing fluid intake will not help.Physical therapy will not decrease the patient's symptoms. An escharotomy should be performed.Debridement will not release the constricted blood supply. An escharotomy is needed. The correct answer is: Perform an escharotomy.

During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? Select one: a. Observe the patient's respiratory effort. b. Palpate extremities for capillary refill time. c. Examine the patient for any external bleeding. d. Check the patient's level of consciousness.

Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. The correct answer is: Observe the patient's respiratory effort.

A patient with a chronic history of upset stomach takes large doses of antacids. This could upset the body's acid-base balance and lead to Select one: a. metabolic alkalosis. b. respiratory acidosis. c. metabolic acidosis. d. respiratory alkalosis.

Excessive consumption of antacids, which neutralize hydrochloric acid, can lead to metabolic alkalosis. The correct answer is: metabolic alkalosis.

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? Select one: a. Leg exercise help increase the patient's level of consciousness after surgery. b. Leg exercises help to prevent pressure sores to the sacrum and heels. c. Leg exercises improve circulation and prevent venous thrombosis. d. Leg exercises increase the patient's muscle mass postoperatively.

Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patient's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term. The correct answer is: Leg exercises improve circulation and prevent venous thrombosis.

The nurse would correctly identify the medical term for ringworm as: Select one: a. Psoriasis b. Tinea corporis c. Impetigo d. Thrush

Feedback Ringworm is also known as tinea corporis. The correct answer is: Tinea corporis

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

A client recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this client? Select one: a. Fluconazole (Diflucan) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Acyclovir (Zovirax) d. Rifampin (Rifadin)

Fluconazole (Diflucan) is indicated for opportunistic candidiasis infection related to HIV. Trimethoprim/sulfamethoxazole (Bactrim) is indicated for bacterial infections such as urinary tract infection. Rifampin (Rifadin) is used for treatment of tuberculosis. Acyclovir (Zovirax) is an antiviral agent. The correct answer is: Fluconazole (Diflucan)

A 28-year-old male is admitted to the burn unit 2 hours after receiving second- and third-degree burns over 50% of his body surface in an industrial explosion. Abnormal vital signs include low blood pressure and tachycardia. Lab results show a high hematocrit due to: Select one: a. Increased vascular protein secondary to increased metabolism b. Fluid movement out of the vascular space c. Renal failure d. Sickle cell syndrome

Fluid and protein movement out of the vascular compartment results in an elevated hematocrit.Sickle cell syndrome does not result in increased hematocrit.Renal failure can occur, but this does not result in an increase in the hematocrit.Protein loss leads to decreased protein, not increased. The correct answer is: Fluid movement out of the vascular space

A patient needs to be on sodium restriction to help manage high blood pressure. The nurse instructs the patient that snacks that are acceptable to eat include Select one: a. fresh apples. b. tomato juice. c. cheese. d. olives.

Foods that are high in sodium, such as tomato juice, olives, and cheese, should be avoided. The correct answer is: fresh apples.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? Select one: a. The poison control center b. The physical therapy department c. A herpetologist (snake specialist) d. The facility's neurologist

For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management. The correct answer is: The poison control center

The nurse is caring for a patient on strict fluid restriction. He is complaining of thirst and is demanding something to drink. The nurse's best response is Select one: a. "I will be able to give you more water tonight." b. "You need to follow the doctor's orders." c. "Try not to think about being thirsty." d. "Brushing your teeth will keep your mouth moist."

Frequent oral care is important for the oral mucous membranes to remain intact. The correct answer is: "Brushing your teeth will keep your mouth moist."

A client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one does the nurse report to the surgical team as a priority? Select one: a. Chamomile b. St. John's wort c. Valerian root d. Garlic

Garlic interferes with coagulation, increasing the client's risk for bleeding during and after the surgical procedure. This would be a critical piece of information for the surgical team to know. The correct answer is: Garlic

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? Select one: a. Respiratory Acidosis b. Respiratory Alkalosis c. Metabolic Acidosis d. Metabolic Alkalosis

Gastric suction removes acid from the patient leaving in excess the alkaline component of the balance. The pH should be high and the bicarbonate also should be high. The correct answer is: Metabolic Alkalosis

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? Select one: a. "Since I tend to sweat a lot, I use a lot of baby powder." b. "I try not to use cosmetics that contain any type of sunblock." c. "I always wear long sleeves, pants, and a hat when outdoors." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

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. The correct answer is: "I always wear long sleeves, pants, and a hat when outdoors."

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? Select one: a. Granulation b. Purulent drainage c. Eschar d. Slough

Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough-a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal. The correct answer is: Granulation

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? Select one: a. The patient restricts salt to treat prehypertension. b. The patient has a glass of grapefruit juice every day for breakfast. c. The patient drinks 3 to 4 quarts of fluids every day. d. The patient has many concerns about the effects of cyclosporine.

Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems. The correct answer is: The patient has a glass of grapefruit juice every day for breakfast.

A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? Select one: a. "Research has shown the effectiveness of this therapy if I do not forget to take any doses." b. "This treatment does not kill the virus." c. "This medication prevents the virus from replicating in my body." d. "With this treatment, I probably cannot spread this virus to others."

HAART reduces viral load and improves CD4+ T-cell counts, but the client must still protect others from contact with his or her body fluids. HAART inhibits viral replication; it does not kill the virus. Remembering to take all doses of HAART is very important for preventing drug resistance. The correct answer is: "With this treatment, I probably cannot spread this virus to others."

Which statement about the transmission of hepatitis C is correct? Select one: a. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. b. Sweat is a likely body fluid by which to transmit the disease. c. All healthcare workers should be vaccinated for hepatitis C to prevent the disease. d. Airborne Precautions are used for the prevention of hepatitis C.

Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection. Sweat is not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. There is not vaccine for Hepatitis C. The correct answer is: Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection.

Which statement about the transmission of hepatitis C is correct? Select one: a. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. b. Feces are a likely body fluid by which to transmit the disease. c. No precautions are necessary with the use of nail clippers or scissors. d. Airborne Precautions are used for the prevention of hepatitis C.

Hepatitis C is a bloodborne pathogen: Standard precaution. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection. Feces are not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors, so these items should be disinfected regularly. The correct answer is: Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection.

When a patient asks the nurse what hypersensitivity is, how should the nurse respond? Hypersensitivity is best defined as: Select one: a. An excessive or inappropriate response of the immune system to a sensitizing antigen b. A reduced immune response found in most pathologic states c. A normal immune response to an infectious agent d. Antigenic desensitization

Hypersensitivity is an altered immunologic response to an antigen that results in disease or damage to the individual.Hypersensitivity is not a reduced immune response.Hypersensitivity is not a normal response to an infectious agent.Antigenic desensitization is performed to decrease hypersensitivity. The correct answer is: An excessive or inappropriate response of the immune system to a sensitizing antigen

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

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

Hypovolemia in the early stages of burn shock is directly related to: Select one: a. Increased capillary permeability and evaporative water loss b. Bacterial infection of the wound and resulting bacteremia c. Hypometabolism and renal water loss d. Decreased cardiac contractility and shunting of blood away from visceral organs

Hypovolemia occurs due to increased capillary permeability.Decreased cardiac contractility occurs, but this is not the direct cause of hypovolemia.Blood is shunted from the kidneys, so water loss does not occur.Bacterial infection is a risk, but it is not the cause of hypovolemia. The correct answer is: Increased capillary permeability and evaporative water loss

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take? Select one: a. Wait until the patient gets to the operating room and is catheterized. b. Have the patient go to the bathroom. c. Assist the patient to the bathroom. d. Offer the patient a bedpan or urinal

If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a patient needs to void following administration of a sedative, the nurse should offer the patient a urinal. The patient should not get out of bed because of the potential for lightheadedness. The correct answer is: Offer the patient a bedpan or urinal.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? Select one: a. Ask the spouse if he wishes to be present during the resuscitation. b. Request that the client's spouse sit in the waiting room. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. The correct answer is: Ask the spouse if he wishes to be present during the resuscitation.

A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the postanesthesia care unit following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to Select one: a. irrigate the indwelling urinary catheter. b. increase the flow rate of the IV for 10 to 15 minutes. c. apply manual pressure to the patient's bladder. d. notify the surgeon of the findings.

If the urinary flow rate is less than 60 mL for a 2-hour period, the surgeon is notified. The correct answer is: notify the surgeon of the findings.

A 10-year-old male is stung by a bee while playing in the yard. He experiences a severe allergic reaction and has to go to the ER. The nurse providing care realizes this reaction is the result of: Select one: a. Toxoids b. IgE c. IgM d. IgA

IgE is normally at low concentrations in the circulation. It has very specialized functions as a mediator of many common allergic responses.IgE, not toxoids, is the mediator of common allergic response.IgE, not IgA, is the mediator of common allergic response.IgE, not IgM, is the mediator of common allergic response. The correct answer is: IgE

Which statement indicates a correct understanding of antibodies? The most abundant class of antibody in the serum is: Select one: a. IgA b. IgG c. IgM d. IgE

IgG is the most abundant class of immunoglobulins, constituting 80% to 85% of the immunoglobulins in the blood.IgG is the most abundant class of immunoglobulins, not IgM.IgG is the most abundant class of immunoglobulins, not IgA.IgG is the most abundant class of immunoglobulins, not IgE. The correct answer is: IgG

The predominant antibody of a typical primary immune response is: Select one: a. IgG b. IgE c. IgA d. IgM

IgM is the largest immunoglobulin and is the first antibody produced during the initial, or primary, response to antigen.IgM, not IgG, is the largest immunoglobulin and is the first antibody produced during the initial, or primary, response to antigen.IgM, not IgA, is the largest immunoglobulin and is the first antibody produced during the initial, or primary, response to antigen.IgM, not IgE, is the largest immunoglobulin and is the first antibody produced during the initial, or primary, response to antigen. The correct answer is: IgM

In which step of the chain of infection works immunization (vaccines)? Select one: a. Susceptible host b. Infectious agent c. Mechanism of transmission d. Reservoir

Immunization transform the susceptible host in a non-susceptible individual. The correct answer is: Susceptible host

A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. The patient has received antibiotics for 24 hours. What intervention should the nurse include in this patient's care? Select one: a. Teaching about the safe and effective use of topical corticosteroids b. Continue contact precautions for 24 hours more c. Already allow the child to play with other children d. Ensuring that the family knows that impetigo is not contagious

Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective. The correct answer is: Continue contact precautions for 24 hours more

A patient's mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: Select one: a. eczema. b. herpes zoster. c. impetigo. d. diaper dermatitis.

Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (chicken pox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders. The correct answer is: impetigo.

A client with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? Select one: a. Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot b. Improved CD4+ T-cell count and reduced viral load c. Therapeutic highly active antiretroviral therapy (HAART) level d. Positive Papanicolaou (Pap) test

Improved CD4+ T-cell count and reduced viral load reflect the response to prescribed HAART medication. Therapeutic HAART level is the recommended medication combination given to clients with HIV to cause an increase in the CD4+ T-cell count. ELISA and Western blot, if positive, indicate that the client is HIV positive (a fact already known for this client) and do not indicate response to prescribed medication. Pap smears can be precancerous in an HIV-positive client, but the test does not indicate the immune system's response to prescribed medication. The correct answer is: Improved CD4+ T-cell count and reduced viral load

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? Select one: a. "Not everyone will survive a disaster, so it is best to identify those people early and move on." b. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care. The correct answer is: "In a disaster, extensive resources are not used for one person at the expense of many others."

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? Select one: a. Consent should be obtained from the hospital's ethics committee. b. Surgery should be done without informed consent. c. Surgery should be delayed until the parents arrive. d. A social worker should temporarily sign the informed consent.

In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's informed consent. However, every effort must be made to contact the patient's family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign. The correct answer is: Surgery should be done without informed consent.

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Check for a carotid pulse. d. Assess for signs of bleeding.

In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths. The correct answer is: Deliver rescue breaths.

One of the community nurses at the health department is trying to identify how many new cases of acquired immunodeficiency syndrome have occurred in her city this past year. The term that best describes this measurement is: Select one: a. mortality. b. incidence. c. prevalence. d. morbidity.

Incidence will provide the number of cases of a particular disease process. Mortality statistics specify the number of deaths from a given cause. Morbidity statistics specify the prevalence of specific illnesses in a population at a particular time. The correct answer is: incidence.

A 30-year-old male firefighter is badly burned and is admitted to the emergency department. Which of the following would be expected in the first 24 hours? Select one: a. Diuresis b. Increased capillary permeability c. Fluid overload d. Decreased levels of stress hormones

Increased capillary permeability occurs, leading fluid to shift to interstitial spaces.Blood is shunted from the kidneys, so decreased urination occurs.Increased levels of stress hormones are secreted.Hypovolemia, not fluid overload, occurs. The correct answer is: Increased capillary permeability

The nurse is caring for a critically ill client with septic shock. The serum lactate level is elevated. For which acid-base disturbance should the nurse assess? Select one: a. Metabolic acidosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic alkalosis

Increased lactate (lactic acid) levels are associated with hypoxia and metabolic acidosis secondary to anaerobic metabolism. Renal insuficiency, diabetic ketoacidosis, and severe diarrhea are other common causes of metabolic acidosis. Metabolic alkalosis is related to bicarbonate therapy, diuretic use, vomiting, and nasogastric suction. Respiratory acidosis is caused by CO2 retention and impaired pulmonary function, which is inconsistent with elevated lactate levels. Respiratory alkalosis is caused by excessive loss of CO2 through hyperventilation, inconsistent with elevated lactate levels. The correct answer is: Metabolic acidosis

When histamine is released in the body, which of the following responses would the nurse expect? Select one: a. Bronchial dilation b. Vasoconstriction c. Edema d. Constipation

Increased vascular permeability leads to edema and is a direct response to histamine.Histamine produces bronchoconstriction.Histamine produces vasodilation.Histamine does not produce constipation; it increases gastric acidity. The correct answer is: Edema

The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented ´3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the nurse's priority action at this time? Select one: a. Assess urinary output, the IV site, and the client's pain. b. Suction the client and assess anterior and posterior lung sounds. c. Turn the client and perform chest physiotherapy. d. Examine the surgical site; obtain blood pressure and temperature

Initial assessment on the client entering the PACU that should be recorded on the flow chart record includes level of consciousness, temperature, pulse, respirations, oxygen saturation, and blood pressure. In addition, the nurse should examine the surgical area for bleeding. These items were missing from the initial assessment. The correct answer is: Examine the surgical site; obtain blood pressure and temperature.

A nurse is assessing patients on a medical-surgical unit. Which adult patient does the nurse identify as being at greatest risk for insensible water loss? Select one: a. Anxious patient who has tachypnea b. Patient who is on fluid restrictions c. Patient taking furosemide (Lasix) d. Patient who is constipated with abdominal pain

Insensible water loss is water loss through the skin, lungs, and stool. Patients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Patients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The patient taking furosemide will have increased fluid loss, but not insensible water loss. The other two patients on a fluid restriction and with constipation are not at risk for fluid loss. The correct answer is: Anxious patient who has tachypnea

The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician have completed an invasive procedure. What is the next step in handling the instruments used during the procedure? Select one: a. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and sterilization. b. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning. c. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and boiling. d. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and disinfection.

Instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria. The correct answer is: Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and sterilization.

A 23-year-old male received a knife wound in a fight. His scar was sharply elevated, irregularly shaped, and progressively enlarging. This condition is caused by excessive amounts of _____ in the corneum during connective tissue repair. Select one: a. Keratin b. Calcification c. Collagen d. Elastin

Irregular scar formation is due to excessive fibroblast activity and collagen formation.Irregular scar formation is due to excessive fibroblast activity and collagen, not elastin, formation.Irregular scar formation is due to excessive fibroblast activity and collagen, not keratin, formation.Irregular scar formation is due to excessive fibroblast activity and collagen, not calcification, formation. The correct answer is: Collagen

A nurse assesses a young female client who is prescribed isotretinoin. Which question should the nurse ask prior to starting this therapy? Select one: a. "Do you drink alcoholic beverages?" b. "Which method of contraception are you using?" c. "Have you or any family members ever had skin cancer?" d. "Do you spend a great deal of time in the sun?"

Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin. The correct answer is: "Which method of contraception are you using?"

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: Select one: a. pallor. b. jaundice. c. cyanosis. d. iron deficiency.

Jaundice is exhibited by a yellow color, which indicates rising amounts of bilirubin in the blood. It is first noticed in the junction of the hard and soft palate in the mouth and in the scleras. The correct answer is: jaundice.

Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3. What action is most important for the nurse to take? Select one: a. Assess the activated partial thromboplastin time (aPTT). b. Withhold the dose and notify the health care provider. c. Assess the international normalized ratio (INR). d. Administer the prescribed LMWH on schedule.

LMW Heparin doesn't work on platelets but in rare cases can produce an immunologic reaction that produces heparin induced thrombocytopenia (HIT). It tends to be severe. If the platelet count falls below 20,000/mm3, spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. The aPTT is not affected by LMWH, so its assessment is not necessary. Usually, LMWH is given in a low prophylactic dose and does not affect the INR. The correct answer is: Withhold the dose and notify the health care provider.

Displaying her hands, a patient asks, "Do you think my liver is OK? Look at all these liver spots!" The most appropriate response would be: Select one: a. "The spots are normal aging changes and have nothing to do with your liver." b. "Have you recently been exposed to hepatitis?" c. "Don't worry about them. They will fade during the winter." d. "The spots could mean there is something wrong; I will make a note of it."

Lentigines on sun-exposed areas are called liver spots because of their color, but have nothing to do with the liver or any disease process. They are normal changes of aging. The correct answer is: "The spots are normal aging changes and have nothing to do with your liver."

Which factor will help the nurse differentiate leukotrienes from histamine? Select one: a. Time of release b. Chemotactic ability c. Vascular effect d. Site of production

Leukotrienes are released slower and longer than histamine.Leukotrienes and histamine are produced from mast cells.Leukotrienes and histamine have similar vascular effects.Leukotrienes and histamine have similar chemotactic ability. The correct answer is: Time of release

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patient's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? Select one: a. Hyperglycemia b. Azotemia c. Infection d. Falls

Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative patient who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls. The correct answer is: Infection

The implementation that would make a patient with atopic dermatitis more comfortable is to: Select one: a. add alcohol to the bath water. b. increase the room temperature to 78º F to 80º F. c. provide a diet low in fat. d. instruct the patient to wear loose clothing.

Loose clothing and a cool atmosphere allow the skin to stay cool and reduce sweating. Alcohol is drying to the skin. The correct answer is: instruct the patient to wear loose clothing.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: Select one: a. allergy to mosquito bites. b. Rocky Mountain spotted fever. c. Lyme disease. d. rubeola.

Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or papular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy. The correct answer is: Lyme disease.

The nurse is admitting a patient who is scheduled for a hysterectomy. Malignant hyperthermia is a potential postoperative complication. In gathering information on the patient's medical history, the nurse should ask: Select one: a. "Have you ever had any type of malignancy?" b. "Do you currently have an infection?" c. "Has anyone in your family ever had problems with general anesthesia?" d. "Do you think you might have a fever?"

Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs. Susceptibility to this response is inherited. The correct answer is: "Has anyone in your family ever had problems with general anesthesia?"

A patient wants to know which malignant skin lesion is the most serious. The correct response is: Select one: a. Squamous cell carcinoma b. Kaposi sarcoma (KS) c. Basal cell carcinoma d. Malignant melanoma

Malignant melanoma is the most serious skin cancer.Malignant melanoma, not basal cell carcinoma, is the most serious skin cancer.Malignant melanoma, not squamous cell carcinoma, is the most serious skin cancer.Malignant melanoma, not KS, is the most serious skin cancer. The correct answer is: Malignant melanoma

A student asks the nurse what is the best way to assess a client's pain. Which response by the nurse is best? Select one: a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Client's self-report

Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client. The correct answer is: Client's self-report

The nursing instructor reviews instructions with the nursing student on caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? Select one: a. Massages bony prominences b. Re-positions the client every 1 to 2 hours c. Avoids reddened areas d. Uses a moisturizing lotion

Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be re-positioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate. The correct answer is: Massages bony prominences

When the immunoglobulin crosses the placenta, what type of immunity does the fetus receive? Select one: a. Passive b. Active c. Cell-mediated d. Innate

Maternal antibodies that pass across the placenta into the fetus before birth provide passive systemic immunity.Maternal antibodies that pass across the placenta into the fetus before birth provide passive systemic immunity, not active immunity.Maternal antibodies that pass across the placenta into the fetus before birth provide passive systemic immunity, not innate immunity.Maternal antibodies that pass across the placenta into the fetus before birth provide passive systemic immunity, not cell-mediated immunity. The correct answer is: Passive

The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the electronic infusion device being used on the intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take? Select one: a. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. b. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. c. Complete the assessment, remove gloves, and silence the alarm. d. Discontinue the assessment, and assess the intravenous infusion.

Medical asepsis or clean technique includes procedures to decrease the number of organisms present and to prevent the transfer of organisms. Wearing gloves while assessing the dilatation and effacement of a labor and delivery patient, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate. The correct answer is: Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.

A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse? Select one: a. oxycodone (OxyContin) 80 mg twice daily b. amitriptyline (Elavil) 50 mg at bedtime c. meperidine (Demerol) 25 mg every 4 hours d. ibuprofen (Advil) 800 mg 3 times daily

Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management. The correct answer is: meperidine (Demerol) 25 mg every 4 hours

The patient who has had diarrhea for the last 3 days has blood gases of pH of 7.25, HCO3- of 20 mEq/L, and PCO2 of 34 mm Hg. The nurse recognizes these values indicate: Select one: a. respiratory alkalosis. b. metabolic alkalosis. c. metabolic acidosis. d. respiratory acidosis.

Metabolic acidosis shows a low pH, low HCO3-, and as compensation low CO2. The correct answer is: metabolic acidosis.

A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? Select one: a. "The health care provider should be notified 3 months before a planned pregnancy." b. "Drinking alcoholic beverages should be avoided." c. "I will avoid any live vaccines." d. "Any side effects of this drug will be mild."

Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug; this statement indicates the client needs further clarification. Alcoholic beverages increase the risk for hepatotoxicity and should be avoided. Strict birth control is recommended for any client of childbearing age because of the possibility of birth defects. Severe reactions may occur when live vaccines are given because of the immunosuppressive effect of methotrexate. The correct answer is: "Any side effects of this drug will be mild."

A patient with severe psoriasis who is to be treated with a systemic drug, methotrexate, anxiously asks, "Is this drug safe? Are there some side effects I need to know about?" The nurse's best response would be: Select one: a. "We use the drug with many kinds of patients, including cancer patients. You will have periodic blood tests." b. "Yes, it is used to treat cancer and psoriasis, but it has no severe side effects." c. "I don't know if it is used with cancer patients or not, but the drug can be used when conditions are as severe as yours." d. "No, it is not a cancer drug, but you should ask your physician about concerns regarding your therapy."

Methotrexate is an immunosuppressive drug used to treat psoriasis that is nonresponsive to other protocols. Periodic blood tests are done to assess for leukopenia. Options 1 and 2 are erroneous information. Option 4 does not answer the patient's question. The correct answer is: "We use the drug with many kinds of patients, including cancer patients. You will have periodic blood tests."

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? Select one: a. Administer warmed intravenous fluids to the client. b. Reposition the client into a prone position. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client's trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia. The correct answer is: Administer warmed intravenous fluids to the client.

The female client with rheumatoid arthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? Select one: a. Explain to the HH aide that the client should get up and take a warm shower. b. Arrange an appointment for the client to visit her healthcare provider c. Tell the HH aide to allow the client to stay in bed until the pain goes away. d. Instruct the HH aide to get the client up to a chair and give her a bath.

Movement and warm or hot water will help decrease the pain; the worst thing the client can do is not to move. The HH aide should encourage the client to get up and take a warm shower or bath. The correct answer is: Explain to the HH aide that the client should get up and take a warm shower.

A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The best initial action by the nurse is to Select one: a. order the patient a clear liquid diet until the nausea decreases. b. consult with the health care provider about using a different opioid. c. administer the ordered antiemetic medication. d. tell the patient that the nausea will subside in about a week.

Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the antiemetic medication and allow the patient to eat. The correct answer is: administer the ordered antiemetic medication.

The nurse is reviewing principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? Select one: a. Cutaneous b. Visceral c. Neuropathic d. Referred

Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources. The correct answer is: Neuropathic

A 20-year-old male shoots his hand with a nail gun while replacing roofing shingles. Which of the following cell types would be the first to aid in killing bacteria to prevent infection in his hand? Select one: a. Eosinophils b. Leukotrienes c. Monocytes d. Neutrophils

Neutrophils are the predominant phagocytes in the early inflammatory site, arriving within 6 to 12 hours after the initial injury.Eosinophils help limit and control inflammation.Leukotrienes are activators of the inflammatory response.Monocytes enter much later and replace leukocytes. The correct answer is: Neutrophils

The nurse is assisting in the care of a patient who will receive a unit of blood. The appropriate solution to infuse through a parallel infusion set before and after the infusion is Select one: a. 10% dextrose in water. b. normal saline. c. 5% dextrose in water. d. lactated Ringer's solution.

Normal saline is the only solution used in conjunction with infusion of a blood product. The correct answer is: normal saline.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather? Select one: a. Potassium b. Serum albumin c. Vitamin E d. Creatine kinase

Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing. The correct answer is: Serum albumin

The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? Select one: a. "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." b. "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." c. "RA is inflammatory. OA is degenerative." d. "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation."

OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints; this statement by the client indicates the need for further teaching. RA is indeed an inflammatory process, while OA is a degenerative process. Research is being done to find a possible genetic cause for OA, but age, trauma, obesity, and occupation are the main causes of degeneration. RA occurs most often in women, usually between 35 and 45 years of age, whereas older age is a cause of OA. The correct answer is: "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."

Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? Select one: a. Ask the patient about whether pain control is effective. b. Monitor sedation using the sedation assessment scale. c. Check the respiratory rate every 2 hours. d. Assess the skin under the heating pad.

Obtaining the respiratory rate is included in NAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice. The correct answer is: Check the respiratory rate every 2 hours.

An older client has returned to the surgical unit after a total hip replacement. The client is confused, moving on bed and restless. What intervention by the nurse is most important to prevent injury related to the surgical site? Select one: a. Restrain the client's hands. b. Use an abduction pillow. c. Administer mild sedation. d. Keep all four siderails up.

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 client's mental status and should be avoided. Using all four siderails may be considered a restraint and research has demostrated that confused patients climb the siderails falling from higher. Hand restraints are not necessary in this situation. The correct answer is: Use an abduction pillow.

The nurse is caring for the postoperative patient who has had spinal anesthesia. The nurse would place highest priority on reporting which of these assessments? Select one: a. Blood pressure of 126/78 b. Voided 300 mL c. Pulse rate of 78 beats per minute d. Complaints of a headache

One complication of spinal anesthesia is postspinal headache. It is caused by the leaking of cerebrospinal fluid at the puncture site. The correct answer is: Complaints of a headache

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? Select one: a. To enhance peripheral circulation b. To prevent chronic obstructive pulmonary disease (COPD) c. To promote optimal lung expansion d. To prevent pneumothorax

One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation. The correct answer is: To promote optimal lung expansion

When an aide asks the nurse what is a purpose of the inflammatory process, how should the nurse respond? Select one: a. To lyse cell membranes of microorganisms b. To provide specific responses toward antigens c. To create immunity against subsequent tissue injury d. To prevent infection of the injured tissue

One purpose of the inflammatory process is to prevent infection and further damage by contaminating microorganisms.Specific response toward antigens is a part of the complement system that assists in the inflammatory response, but not its purpose.Lysis of cell membranes is part of the process of phagocytosis, which removes foreign material, but this is not the purpose of the inflammatory response.Immunity cannot be achieved against future tissue injury. The correct answer is: To prevent infection of the injured tissue

Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response? Select one: a. Orient to date, time, and place b. Passive range-of-motion exercises c. Rest, ice, compression, and elevation d. Turn, cough, and deep breathe

One sign of the inflammatory response, particularly after an injury, is swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide support-particularly if it is an extremity-and elevating the injured area will help to decrease swelling or edema. Turn, cough, and deep breathe is utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many different types of patients who may be confused. Passive range of motion is utilized for individuals who need to improve movement of their extremities, including immobilized patients. The correct answer is: Rest, ice, compression, and elevation

A hospital unit is participating in a bioterrorism drill. A "client" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "client"? Select one: a. Droplet Precautions b. Airborne Precautions c. Standard Precautions d. Contact Precautions

Only Standard Precautions are needed. No other special precautions are required for the "client" because inhalation anthrax is not spread person to person. The correct answer is: Standard Precautions

A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to Select one: a. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. c. consult with the health care provider about using a different treatment protocol to control the patient's pain. d. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal

PCAs are best for controlling acute pain; this patient's history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA. The correct answer is: consult with the health care provider about using a different treatment protocol to control the patient's pain.

Which statement indicates that the nurse understands the pain experienced by an elderly person? Select one: a. "Older individuals perceive pain to a lesser degree than do younger individuals." b. "Pain indicates pathology or injury and is not a normal process of aging." c. "Pain is a normal process of aging and is to be expected." d. "Older persons must learn to tolerate pain."

Pain indicates pathology or injury and should never be considered something that an elderly person should expect or tolerate. Pain is not a normal process of aging, and there is no evidence that pain perception is reduced with aging. The correct answer is: "Pain indicates pathology or injury and is not a normal process of aging."

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as Select one: a. referred pain. b. neuropathic pain. c. somatic pain. d. breakthrough pain.

Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. The correct answer is: breakthrough pain.

A patient diagnosed with colon cancer is being prepared for palliative surgery to correct an intestinal obstruction. The nurse understands that palliative surgery is: Select one: a. the removal and study of tissue to make a diagnosis. b. done to relieve symptoms or improve function without correcting the basic problem. c. done to remove diseased tissue or to correct defects. d. done to correct serious defects that only affect appearance.

Palliative surgery is done only to relieve symptoms or improve function. It is not curative. The correct answer is: done to relieve symptoms or improve function without correcting the basic problem.

The nurse is caring for an older adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? Select one: a. "The bus is coming to pick me up from the senior center three times a week so I can play cards." b. "I do not know how long my wife will be able to take care of me at home." c. "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." d. "I do not know how much longer my neighbor can continue to help clean my house."

Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively. The correct answer is: "The bus is coming to pick me up from the senior center three times a week so I can play cards."

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include Select one: a. A diet low in calories and fat. b. Muscular pain. c. Shortness of breath. d. Alteration in level of consciousness

Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors. The correct answer is: Alteration in level of consciousness.

The nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia, and the fronts of both legs. Using the rule of nines, the nurse would document that the burn size as: Select one: a. 17%. b. 37%. c. 25%. d. 13%.

Per the rule of nines, the front trunk equals 18, the fronts of the legs equal 18, and the genitalia equal 1. The correct answer is: 37%.

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? Select one: a. Transduction b. Modulation c. Transmission d. Perception

Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain. The correct answer is: Perception

The nurse is assessing a patient recently admitted with diagnostic of polymyositis. Which finding of this disease requires priority intervention to prevent serious complications? Select one: a. Shoulder girdle muscle weakness b. Muscle pain c. Dysphagia d. Purple rash

Pharyngeal muscle weakness produces dysphagia, risk of aspiration and airway obstruction. The other are also manifestations of polymyositis, but require less priority nursing interventions compared with dysphagia. The correct answer is: Dysphagia

A 40-year-old female is diagnosed with SLE. Which of the following findings would be considered a symptom of this disease? Select one: a. Photosensitivity b. Gastrointestinal ulcers c. Rash on trunk and extremities d. Decreased glomerular filtration rate

Photosensitivity is one of the 11 common clinical findings in SLE.Gastrointestinal ulcers are not a finding in SLE.Proteinuria is a symptom of SLE.A rash on the face is a symptom, but not a rash on the body. The correct answer is: Photosensitivity

Which skin condition will the emergency department nurse assess first? Select one: a. Red bony prominences b. Localized redness of the surgical site c. Pitting edema d. Poor skin turgor

Pitting edema indicates an electrolyte, cardiac, or renal insufficiency. Localized redness of the surgical site is the body's normal response to trauma. Poor skin turgor is not an urgent finding; it may be caused by age or dehydration. Bony prominences that are red are an important finding, but are not the first priority in this situation. The correct answer is: Pitting edema

The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? Select one: a. Cystic fibrosis b. Iron deficiency anemia c. Isolated periods of severe malnutrition d. Psoriasis

Pitting of the nails may be associated with plate thickening and onycholysis and most often involves several or all of the fingernails; it is seen in clients with psoriasis and alopecia areata. Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau's grooves are a sign of isolated periods of severe malnutrition. The correct answer is: Psoriasis

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? Select one: a. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes. d. Plasmapheresis will eliminate eosinophils and basophils from blood.

Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. The correct answer is: Plasmapheresis will remove antibody-antigen complexes from circulation.

When preparing a client newly diagnosed with human immune deficiency virus (HIV) and the significant other for discharge, which explanation by the nurse accurately describes proper condom use? Select one: a. "Always position the condom with a space at the tip of an erect penis." b. "Condoms should be used when lesions are present on the penis." c. "Make sure it fits loosely to allow for penile erection." d. "Use adequate lubrication, such as petroleum jelly."

Positioning the condom with a space at the tip of the erect penis allows for the collection of semen at the tip of the condom. Condoms must be used by HIV-infected people at all times for sexual activity, with or without the presence of lesions. Condoms should be applied on an erect penis and should fit snugly, leaving space without air at the tip. Lubricants should be water-based only. The correct answer is: "Always position the condom with a space at the tip of an erect penis."

A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? Select one: a. Hypotension b. Hyperkalemia c. Infection d. Fluid volumen deficit

Prednisone is a corticosteroid that may cause fluid and sodium retention. It can cause gastric distress and irritation and usually is taken with food or an antacid. Prednisone decreases the immune response, increasing the susceptibility for infection. It can also cause osteoporosis. Hypertension (not hypotension) is an adverse effect of prednisone. The correct answer is: Infection

When the nurse brings a client's preoperative medications, the client responds, "I don't need that. I had a good night's sleep last night." What is the nurse's best response? Select one: a. "Let me teach you about your medications for surgery." b. "The doctor ordered this medication so you should take it." c. "I will ask your surgeon if you have to take the medication." d. "I will make a note that you refused to take the medication."

Preoperative medications can include sedatives but are often given to prevent laryngospasm and to help reduce pharyngeal and gastric secretions. The client must be fully aware of the rationale for all medications and the risks of not taking them. The correct answer is: "Let me teach you about your medications for surgery."

A 25-year-old male is in a car accident and sustains a fracture to his left femur with extensive soft tissue injury. The pain associated with the injury is related to: Select one: a. Histamine and serotonin b. Kinins and prostaglandins c. Vasoconstriction d. Immune complex formation

Prostaglandins cause increased vascular permeability, neutrophil chemotaxis, and pain by direct effects on nerves. Kinins also promote pain.Prostaglandins produce pain; histamine promotes vasodilation.Prostaglandins produce pain, not vasoconstriction.Prostaglandins produce pain, not the immune complex. The correct answer is: Kinins and prostaglandins

In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? Select one: a. Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma b. High risk for inadequate nutrition related to acquired secondary immune deficiency and Candida albicans c. Potential for infection related to recurring opportunistic infections d. Mouth sores related to Candida albicans secondary to acquired secondary immune deficiency

Protecting the client from further opportunistic infection such as Candida albicans is a priority. Loss of social contact is not a priority problem with an opportunistic infection. Mouth sores would be the secondary concern because Candida albicans causes the mouth sores. Nutrition will be affected because of Candida albicans; however, it is not a priority. The correct answer is: Potential for infection related to recurring opportunistic infections

A 40-year-old female is diagnosed with skin cancer. Her primary care provider explains that the most important risk factor for skin cancer is: Select one: a. Amount of sun exposure over age 50 b. Lifetime amount of sun exposure c. Living in equatorial regions where the sun is most intense d. Amount of direct sun exposure at a young age

Protection from the sun, particularly during the childhood years of life, significantly reduces the risk of skin cancer in later years.Protection from the sun at a young age, not after 50, is the most important way to decrease cancer risk.Protection from the sun, particularly during the childhood years of life, significantly reduces the risk of skin cancer in later years.Protection from the sun, particularly during the childhood years of life, not avoiding equatorial regions, significantly reduces the risk of skin cancer in later years. The correct answer is: Amount of direct sun exposure at a young age

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased Select one: a. Protein. b. Vitamin E. c. Carbohydrates. d. Fat.

Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing. The correct answer is: Protein.

A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? Select one: a. Collaborate with the client to select foods that are high in calories. b. Discuss the need to avoid foods that are spicy or irritating. c. Assess the perianal area every 8 hours for signs of skin breakdown. d. Provide oral care to the client before meals to enhance appetite

Providing oral care is within the scope of practice of unlicensed personnel such as nursing assistants. Diet planning, assessment, and client teaching are higher-level actions that require more broad education and scope of practice; these actions should be done by licensed staff. The correct answer is: Provide oral care to the client before meals to enhance appetite.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? Select one: a. Assess the limb for compartment syndrome. b. Massage the frostbitten areas. c. Wrap the limb with a compression dressing. d. Administer intravenous morphine.

Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics. The correct answer is: Administer intravenous morphine.

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? Select one: a. The Brief Pain Inventory b. The Faces Pain Scale-Revised (FPS-R) c. A numeric rating scale d. The Descriptor Scale

Rating scales can be introduced at the age of 4 or 5 years. The Faces Pain Scale-Revised (FPS-R) is designed for use by children and asks the child to choose a face that shows "how much hurt (or pain) you have now." Young children should not be asked to rate pain by using numbers. The correct answer is: The Faces Pain Scale-Revised (FPS-R)

A 46-year-old male presents with severe pain, redness, and tenderness in the right big toe. He was diagnosed with gouty arthritis. He is at risk for developing: Select one: a. Cholelithiasis b. Renal stones c. Myocarditis d. Liver failure

Renal stones are 1000 times more prevalent in individuals with primary gout than in the general population. For this reason should be recommended consuming 2-3 L of fluids per day.Renal stones, not cholelithiasis, are a risk factor in gout.Renal stones, not myocarditis, are a risk factor in gout.Renal stones, not liver failure, are a risk factor in gout. The correct answer is: Renal stones

Which acid-base imbalance does the nurse anticipate the client with morbid obesity may develop? Select one: a. Respiratory alkalosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory acidosis

Respiratory acidosis is related to CO2 retention secondary to respiratory depression, inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion, which are common in morbidly obese clients who experience inadequate chest expansion owing to their size and work of breathing. Respiratory alkalosis usually is caused by excessive loss of CO2 through hyperventilation secondary to fever, central nervous system lesions, and salicylates. The correct answer is: Respiratory acidosis

Nurse Mary is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? Select one: a. Ring or donut b. Gel flotation pad c. Water bed d. Polyurethane foam mattress

Ring or donut produce pressure in localized areas of skin favoring pressure ulcers. The correct answer is: Ring or donut

When a nurse cares for a patient with systemic lupus erythematosus (SLE), the nurse remembers this disease is an example of: Select one: a. Alleimmunity b. Autoimmunity c. Homoimmunity d. Alloimmunity

SLE is the most common, complex, and serious of the autoimmune disorders.SLE is an autoimmune disorder, not alloimmune.SLE is an autoimmune disorder not homoimmune.SLE is an autoimmune disorder not alleimmune. The correct answer is: Autoimmunity

The nurse is performing preoperative teaching with an older adult client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation the night before. Which action is a priority? Select one: a. Encourage the client to drink plenty of juice. b. Administer antibiotics with a sip of water. c. Teach the client to eat only low-fat foods the night before surgery. d. Tell the client not to get up and go to the bathroom alone

Safety is the priority, and the older adult client can become exhausted and may fall. Antibiotics, if ordered, would be administered with a sip of water, but this is not the priority. The client would not be encouraged to drink juice, because this is not a clear liquid. The correct answer is: Tell the client not to get up and go to the bathroom alone.

Surgical wounds generally heal by which intention? Select one: a. First b. Third c. Second d. Mixed

Second intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is debrided and inflammation subsides. There is no such thing as mixed intention healing. The correct answer is: First

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? Select one: a. Third b. First c. Second d. Mixed

Second-intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is debrided and inflammation subsides. There is no such thing as mixed-intention healing. The correct answer is: Second

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the client's care plan? Select one: a. Client-controlled analgesia with a basal rate b. Round-the-clock analgesia with PRN analgesics c. As-needed pain medication after therapy d. Pain medications prior to therapy only

Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy. The correct answer is: Round-the-clock analgesia with PRN analgesics

A patient with a history of heart failure is at risk for fluid overload. What sign or symptom would the nurse anticipate finding during the assessment? Select one: a. Decreased blood pressure b. Crackles in the lungs c. Weak thready pulse d. Weight loss

Signs of overhydration include weight gain, slow bounding pulse, elevated blood pressure, crackles in the lungs, and possibly edema. The correct answer is: Crackles in the lungs

A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period? Select one: a. Auscultate breath sounds. b. Check pupil reaction to light. c. Palpate peripheral pulses. d. Listen to heart sounds.

Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient's admission diagnosis. The correct answer is: Auscultate breath sounds.

During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. Which action by the nurse is best? Select one: a. Call the surgeon to cancel the surgery. b. Give a nebulizer treatment. c. Perform a respiratory assessment. d. Have baseline laboratory studies drawn.

Smoking increases the client's risk for atelectasis and hypoxia. The nurse should assess the client for signs of respiratory disease. The physician will need to know this information but will not necessarily cancel the operation. Baseline laboratory studies need to be ordered by the physician. There is no indication for giving a nebulizer to this client. The correct answer is: Perform a respiratory assessment.

A nurse is assessing pain in an older adult. What action by the nurse is best? Select one: a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Sit down, ask one question at a time, and allow the client to answer. d. Question the client about new pain only, not normal pain from aging.

Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging. The correct answer is: Sit down, ask one question at a time, and allow the client to answer.

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? Select one: a. Stage 4. b. Stage 3. c. Stage 2. d. Stage 1

Stage 3 is a full thickness loss of skin with depth penetrating until subcutaneous tissue. The correct answer is: Stage 3.

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage Select one: a. I. b. II. c. IV. d. III.

Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer. The correct answer is: I.

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Select one: a. Stage III b. Stage IV c. Stage II d. Stage I

Stage II: partial thickness. The correct answer is: Stage II

The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. It is important for the nurse to utilize _____ Precautions. Select one: a. Protective b. Contact c. Droplet d. Standard

Standard Precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact Precautions apply to individuals with colonization of infection such as MRSA. Protective Precautions apply to individuals who have undergone transplantations. Droplet Precautions focus on diseases that are transmitted by large droplets. The correct answer is: Standard

In caring for the patient who is HIV positive, the nurse should: Select one: a. use Standard Precautions. b. limit visitors. c. monitor intake of salt. d. wear gown, gloves, and mask at all times.

Standard Precautions are adequate during routine nursing care. For invasive procedures, additional personal protective equipment is necessary. The correct answer is: use Standard Precautions.

The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the need for Standard Precautions, the nurse is careful to Select one: a. Don gloves when wearing artificial nails. b. Avoid contact with intact skin without wearing gloves. c. Teach the patient about good nutrition. d. Wear eyewear when emptying a urinary drainage bag.

Standard Precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter. Teaching the patient about good nutrition is positive but does not apply to Standard Precautions. The term Standard Precautions applies to all blood and body fluids except sweat, even if blood is not present. It also applies to nonintact skin and mucous membranes. The correct answer is: Wear eyewear when emptying a urinary drainage bag.

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? Select one: a. Urticaria b. Stridor c. Pruritus d. Anxiety

Stridor indicates airway involvement and warrants immediate intervention, such as use of oxygen and administration of epinephrine. Maintaining the client's airway is the highest priority. Anxiety, urticaria, and pruritus may be symptoms of a reaction, but are not the nurse's highest priority when the client is in respiratory distress. The correct answer is: Stridor

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Select one: a. Hypothyroidism b. Hypertension c. Glaucoma d. Sulfa allergy

Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies. Sulfasalazine (Azulfidine) is not contraindicated in clients with glaucoma, hypertension, or hypothyroidism. The correct answer is: Sulfa allergy

To promote efficient wound healing, which dressing should be applied to a superficial ulcer? Select one: a. Flat and moist b. None c. Thick and dry d. Bulky and dry

Superficial ulcers should be covered with flat, moisture-retaining dressings.Superficial ulcers should be covered with flat and moist dressings, not dry and thick.Superficial ulcers should be covered with flat, not bulky, dressings.Superficial ulcers should be covered with flat, moisture-retaining dressings. Dressings should not be avoided. The correct answer is: Flat and moist

The patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. The nurse responds that it is caused by: Select one: a. Protozoal infection b. Fecal-oral contamination c. Inflammatory response d. Long-term antibiotic therapy

Superinfections such as Clostridium difficile are caused by long-term antibiotic therapy, which kills all the natural flora of the bowel and causes diarrhea. The correct answer is: Long-term antibiotic therapy

The nurse is preparing to bring a young female client to the operating room for a total abdominal hysterectomy (TAH). The client says to the nurse, "I am so glad that I will still be able to have children after this surgery." What is the nurse's best response? Select one: a. "Weren't you taught about your surgery earlier?" b. "You must have misunderstood your surgeon." c. "That is very good news. How many children do you want?" d. "I will call the surgeon to speak with you before surgery."

TAH includes removal of the uterus, which will leave the client unable to have children. The surgeon should be called to speak with the client and explain the surgery before the client is moved to the operating room. The correct answer is: "I will call the surgeon to speak with you before surgery."

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? Select one: a. During the intraoperative period b. When the patient returns from the PACU c. As soon as possible before the surgical procedure d. Upon the patient's admission to the postanesthesia care unit (PACU)

Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this an inopportune time for teaching. Upon the patient's return from the PACU, the patient may remain drowsy. During the intraoperative period, anesthesia alters the patient's mental status, rendering teaching ineffective. The correct answer is: As soon as possible before the surgical procedure

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: Select one: a. ask additional questions regarding environmental irritants that may have caused this condition. b. suspect that this is a compound nevus, which is very common in young to middle-aged adults. c. tell the patient to watch the lesion and report back in 2 months. d. refer the patient because of the suspicion of melanoma on the basis of her symptoms.

The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral. The correct answer is: refer the patient because of the suspicion of melanoma on the basis of her symptoms.

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? Select one: a. 12 b. 13 c. 23 d. 20

The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23. The correct answer is: 23

A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%, respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse's best action? Select one: a. Auscultate lung sounds bilaterally. b. Increase the client's fraction of inspired oxygen (FIO2). c. Attempt to awaken the client. d. "Bag" the client with a resuscitation bag.

The ET tube could have slipped into the right mainstem bronchus. Auscultating the lungs will help to confirm this; then the nurse should call the health care provider because the tube will need to be pulled back. Attempting to awaken the client will not change the asymmetric chest wall expansion, neither will "bagging" the client or increasing the fraction of inspired oxygen (FIO2). Because the client's oxygen saturation is still within an acceptable range, this is not warranted. The correct answer is: Auscultate lung sounds bilaterally.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 9 shallow breaths/min. The client's oxygen saturation is 87%. What action should the nurse perform first? Select one: a. Give naloxone (Narcan). b. Apply oxygen at 4 L/min. c. Attempt to arouse the client. d. Notify the Rapid Response Team.

The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score. The correct answer is: Attempt to arouse the client.

A patient is scheduled for a bowel resection in the morning and the patient's orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Select one: a. Facilitating better absorption of medications b. Preventing potential contamination of the peritoneum c. Preventing aspiration of gastric contents d. Preventing the accumulation of abdominal gas postoperatively

The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The patient should expect to develop gas in the postoperative period. The correct answer is: Preventing potential contamination of the peritoneum

A client tells the nurse that he has an advance directive with durable power of attorney for health care. The client asks how the advance directive will affect the surgery. What is the nurse's best response? Select one: a. "If you are unable to make a decision, your designee will be asked." b. "The surgical staff will resuscitate only if your heart stops during the operation." c. "You will not be intubated during general anesthesia for the surgery." d. "There will be no effect on your surgery."

The advance directive with durable power of attorney indicates whom the client wishes to designate for medical decisions if he is unable to make decisions for himself. An advance directive with power of attorney does not eliminate the need for intubation during surgery. Although the document does not affect the procedure, simply acknowledging that fact does not help the client understand. If the client's heart stops during the operation and the client has not made his or her wishes known about that situation, the power of attorney would be consulted. The correct answer is: "If you are unable to make a decision, your designee will be asked."

A 20-year-old female is applying for nursing school and is required to be tested for immunity against several illnesses. Testing that looks at which of the following would be the best to determine immunity? Select one: a. Precipitation b. Titer c. Culture and sensitivity d. Agglutination

The amount of antibody in a serum sample is referred to as the titer; a higher titer indicates more antibodies.Culture and sensitivity determine the type of organism that causes an infection, and sensitivity identifies the antibody it is sensitive to.The amount of antibody in a serum sample is referred to as the titer, not agglutination.The amount of antibody in a serum sample is referred to as the titer, not precipitation. The correct answer is: Titer

A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? Select one: a. Continue to monitor the patient's status. b. Give the prescribed PRN naloxone (Narcan). c. Notify the health care provider. d. Remove the fentanyl patch.

The assessment data indicate possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring also are needed, but the patient's data indicate that more rapid action is needed. The correct answer is: Remove the fentanyl patch.

The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a localized inflammatory response, the nurse should assess for which of these signs and symptoms? Select one: a. Dizziness and disorientation to time, date, and place b. Edema, redness, tenderness, and loss of function c. Chest pain, shortness of breath, and nausea and vomiting d. Fever, malaise, anorexia, and nausea and vomiting

The body's cellular response to an injury is seen as inflammation. Inflammation can be triggered by physical agents, chemical agents, or microorganisms. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as nausea and vomiting. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration. The correct answer is: Edema, redness, tenderness, and loss of function

A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes:36-year-old female with bilateral leg burnsNKDAHealth history of asthma and seasonal allergies Wound Assessment: Bilateral leg burns present with a red and wet appearance after blister debridement. Client rates pain 7/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? Select one: a. Infected burns b. Full thickness c. Superficial d. Partial-thickness deep

The characteristics of the client's wounds meet the criteria for a partial-thickness injury. Lesions in which color is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer are ful- thickness burns. Partial-thickness burns appear pink to red and are painful. Superficial burns are pink to red and are also painful. There is not evidence of infection in the description. The correct answer is: Partial-thickness deep

Which action by the surgical nursing staff indicates that additional teaching is required about nurses' roles and responsibilities in the operating room? Select one: a. The circulating nurse and the anesthesiologist accompany the client to the postanesthesia care unit. b. The circulating nurse prepares the surgical site before the client is covered with sterile drapes. c. The circulating nurse goes to the blood bank to pick up 2 units of fresh-frozen plasma for the client. d. The scrub nurse monitors the amount of irrigation fluid that is used during surgery.

The circulating nurse should not leave the operating room to pick up fresh-frozen plasma and should delegate the job to unlicensed personnel instead. The other actions are appropriate. The correct answer is: The circulating nurse goes to the blood bank to pick up 2 units of fresh-frozen plasma for the client.

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? Select one: a. Epinephrine (Adrenalin) b. Monteleukast (Singulair) c. Cromolyn sodium (Nasalcrom) d. Fexofenadine (Allegra)

The client is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic used to treat anaphylaxis. Fexofenadine (Allegra) is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium (Nasalcrom) is a mast cell-stabilizing drug; it is used to prevent symptoms of allergic rhinitis, but is not useful during an acute episode. Monteleukast (Singulair) is a leukotriene antagonist; it is also used to prevent symptoms of allergic rhinitis, but is likewise not useful during an acute episode. The correct answer is: Epinephrine (Adrenalin)

A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene? Select one: a. Reinforces client teaching about using the PCA pump b. Assesses the client's pain level per agency policy c. Presses the button when the client cannot reach it d. Monitors the client's respiratory rate and sedation

The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate. The correct answer is: Presses the button when the client cannot reach it

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? Select one: a. "After you bathe, put lotion on before your skin is totally dry." b. "Use antimicrobial soap to avoid infection of cracked skin." c. "Use moisturizer several times a day to minimize dryness." d. "Take a shower instead of soaking in the bathtub."

The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap. The correct answer is: "After you bathe, put lotion on before your skin is totally dry."

The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse's next action? Select one: a. Discontinue the PCA immediately. b. Push the PCA control for the client. c. Assess the client's respiratory status. d. Keep the client awake as much as possible.

The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken. The correct answer is: Assess the client's respiratory status.

The nurse has just completed preoperative teaching with a client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed? Select one: a. "I will go to the bathroom as soon as I receive all my preoperative medications." b. "I won't have to worry about putting my makeup on tomorrow morning." c. "When I brush my teeth before surgery, I will be sure to spit out the water." d. "I will remember to wear my glasses tomorrow instead of my contact lenses."

The client should void before receiving any preoperative medication. The medication could make the client sleepy and at risk for falling. The other statements are correct. The correct answer is: "I will go to the bathroom as soon as I receive all my preoperative medications."

A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurse's first action? Select one: a. Orient the client and remain with him or her. b. Call the surgeon for an intraoperative report. c. Assess the client's level of pain. d. Notify the physician on call.

The client who is not oriented is at risk of falling. The nurse should remain with the client to ensure safety, and should assign another staff member to the client if care has to be given to others. The client should not be left alone. The correct answer is: Orient the client and remain with him or her.

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

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

An elder client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Select one: a. Avoid using a straight razor. b. Use an abduction pillow. c. Re-orient frequently. d. Keep heels off the bed.

The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin, including when shaving. Using an abduction pillow between the legs is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning, but an abductor pillo can't be used when ambulating.. Keeping the heels off the bed prevents pressure ulcers, no in relation with anticoagulation and bleeding. Changes in mental status can occur immediately after surgery as a result of anesthesia, but reorientation is not related with anticoagulants and bleeding risk. The correct answer is: Avoid using a straight razor.

A client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Select one: a. Keep heels off the bed. b. Avoid using a straight razor. c. Re-orient frequently. d. Use an abduction pillow to ambulate.

The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin, including when shaving. Using an abduction pillow between the legs is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning. Keeping the heels off the bed prevents pressure ulcers during the in-hospital postoperative period. Changes in mental status can occur immediately after surgery as a result of anesthesia. The correct answer is: Avoid using a straight razor.

The nurse is conducting preoperative assessments. Which client does the nurse teach about the possibility of developing a venous thromboembolism (VTE)? Select one: a. Client with a latex allergy b. Client undergoing hip replacement surgery c. Client with body mass index (BMI) of 19 d. Client with an international normalized ratio (INR) of 2.2

The client will have limited mobility following hip replacement surgery, increasing the risk of postoperative venous thromboembolism (VTE). The other conditions will not increase the risk of VTE. The correct answer is: Client undergoing hip replacement surgery

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? Select one: a. "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must." b. "I'm letting my husband do most of the cooking, but I help plan the menus." c. "My husband is getting used to having sex only once a month." d. "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier."

The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required. Being involved in the meal process is a productive coping strategy. The client's statement about the positive effects of etanercept therapy indicates productive coping because it describes improved mobility. Expressing concerns about the future but then identifying a plan is a productive coping strategy. The correct answer is: "My husband is getting used to having sex only once a month."

A nurse assesses an older client in an extended care facility who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take before consulting the physician? Select one: a. Place the client in contact precautions until diagnostic confirmation. b. Administer a prescribed over-the-counter topical hydrocortisone. c. Assess the client's airway and breathing sounds. d. Cut the nails and apply gloves to minimize scratching.

The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder. The correct answer is: Place the client in contact precautions until diagnostic confirmation.

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? Select one: a. Remove the stinger with tweezers and encourage rest. b. Elevate the site and notify the person's next of kin. c. Administer an EpiPen from the first aid kit and call 911. d. Administer diphenhydramine (Benadryl) and apply ice.

The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis. The correct answer is: Administer an EpiPen from the first aid kit and call 911.

A female client is brought to the emergency department with second- and third-degree burns on the total left arm, total left leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? Select one: a. 36% b. 45% c. 27% d. 18%

The correct answer is: 45%

A major reason for the shift of fluid into the interstitial space in patients with liver disease and malnutrition is: Select one: a. Increased interstitial oncotic pressure b. Decreased capillary fluid pressure c. Decreased capillary oncotic pressure d. Increased excretion of aldosterone

The correct answer is: Decreased capillary oncotic pressure

Which is important to include in the plan of care for the individual with hypercalcemia? Select one: a. Only non-weight-bearing activity b. Oral fluids that promote alkaline urine c. Increased fluid intake d. Promotion of vitamin D intake

The correct answer is: Increased fluid intake

When Trousseau's sign is elicited during diagnostic tests for hypocalcemia, the nurse is: Select one: a. Inflating a blood pressure cuff on the upper arm b. Hyperextending the patient's neck c. Tapping the patient's face lightly over the facial nerve d. Flexing the patient's knees toward the chest

The correct answer is: Inflating a blood pressure cuff on the upper arm

Signs and symptoms of hypocalcemia would occur with: Select one: a. Excess parathyroid hormone b. Low ionized calcium c. Low serum albumin and total calcium d. Excess vitamin D intake

The correct answer is: Low ionized calcium

Which correctly describes the sequence of events leading to an infection? Select one: a. Pathogen, reservoir, portal of entry, susceptibility of host b. Carrier, pathogen, portal of entry, susceptibility of host c. Causative agent, susceptibility of host, pathogen d. Susceptibility of host, pathogen, portal of entry, carrier

The correct answer is: Pathogen, reservoir, portal of entry, susceptibility of host

A patient is receiving digoxin for a heart condition. Cardiac monitoring should be implemented if serum lab values show: Select one: a. Serum calcium level of 11.0 mg/dl b. Serum sodium level of 154 mEq/L c. Serum magnesium of 1.5 mEq/L d. Potassium level of 2.5 mEq/L

The correct answer is: Potassium level of 2.5 mEq/L

Which statement regarding the causes, consequences, or treatment of fever is false? Select one: a. It is a protective response to pathogens b. Increased perspiration may lead to dehydration c. Temperature is rapidly reduced to prevent seizures d. Shivering results in increased heat production

The correct answer is: Temperature is rapidly reduced to prevent seizures

Which factor places the patient at risk for losing total body sodium? Select one: a. Receiving IV 0.9% NaCl b. Thiazide diuretic therapy c. Congestive heart failure d. Excessive water ingestion

The correct answer is: Thiazide diuretic therapy

Which nursing activity is included in the standard of care for preventing electrolyte disturbances in patients with NG suction? Select one: a. Replacing lost sodium via the NG tube b. Removing the NG tube after 48 hours c. Allowing regular sips of fluids d. Using normal saline when irrigating

The correct answer is: Using normal saline when irrigating

A 30-year-old male was diagnosed with HIV. Which of the following treatments would be most effective? Select one: a. Protease inhibitors b. Highly active antiretroviral therapy (HAART) c. Reverse transcriptase inhibitors d. Entrance inhibitors

The current regimen for treatment of HIV infection is a combination of drugs, termed highly active antiretroviral therapy (HAART).Approved AIDS medications are classified by mechanism of action; nucleoside and nonnucleoside inhibitors of reverse transcriptase (reverse transcriptase inhibitors).Inhibitors of the viral protease (protease inhibitors) are also part of therapy for AIDS.Inhibitors of viral entrance into the target cell (entrance inhibitors) are also part of the treatment of AIDS. The correct answer is: Highly active antiretroviral therapy (HAART)

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? Select one: a. Rapid HIV antibody testing b. Enzyme immunoassay c. Viral load testing d. Immunofluorescence assay

The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. The correct answer is: Viral load testing

Which observed action indicates that the nurse is performing the surgical scrub correctly? Select one: a. The soap is rinsed off so that the water runs down to the hands. b. The surgical mask is put on before starting the surgical scrub. c. A paper towel is used to turn off the faucet handle. d. A small brush is used to scrub under nails and wedding ring.

The facemask must be donned before the surgical scrub is started. Jewelry is removed before scrubbing. The hands and the arms are positioned so that water falls away from them and does not run "up" or "down" the hands and arms. Water flow is controlled by foot pedals. The correct answer is: The surgical mask is put on before starting the surgical scrub.

The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and says to the nurse, "I feel like something ripped in my incision." A large amount of blood is suddenly apparent on the client's gown near the incision. What action does the nurse take first? Select one: a. Ease the client to the floor and call for assistance. b. Call the Rapid Response Team to assess the client. c. Put immediate pressure over the incision with the hands. d. Lift up the gown and take off the dressing.

The first action of the nurse should be to ease the client to the floor to reduce tension on the incision. This will help keep organs within the abdominal cavity and will help prevent the client from fainting and falling to the floor. The nursing staff should return the client to bed, and the nurse needs to reinforce the dressing while leaving the original one intact. The surgeon or the Rapid Response Team should be notified. The correct answer is: Ease the client to the floor and call for assistance.

A patient who has just undergone a colon resection complains to the nurse that he felt something "pop" under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. The nurse's first action should be to: Select one: a. replace the dressing; dehiscence is normal. b. pull the wound edges together and replace the dressing. c. cover the wound with sterile dressings saturated with normal saline. d. call the physician.

The first action of the nurse should be to prevent damage from drying of the exposed organs by covering the wound with saline-saturated dressings and then calling the physician. The correct answer is: cover the wound with sterile dressings saturated with normal saline.

The nurse is working in the postanesthesia care unit (PACU) and receives a client from the operating room (OR). What does the nurse assess first? Select one: a. Client's Foley catheter b. Client's endotracheal tube c. Hemovac drain at the incision site d. Client's nasogastric tube

The first priority for this client is to assess airway, breathing, and circulation postoperatively. Therefore, the patency of the client's endotracheal (ET) tube should be determined first. All other drains should be assessed, but they are not the priority. The correct answer is: Client's endotracheal tube

A nurse is preparing to get a patient out of bed for the first time since surgery. Which step should the nurse take first? Select one: a. Assist the patient from a supine position to a standing position. b. Allow the patient to sit with the head of bed raised to the high-Fowler's position. c. Assist the patient to sit and dangle legs on the side of the bed. d. Place a walker at the side of the bed.

The first step is to raise the head of the bed and let the body adjust to the position change. After a few minutes, the patient can be assisted to sit on the side of the bed with the legs dangling (with feet on floor). Finally, the patient is assisted to a standing position. The correct answer is: Allow the patient to sit with the head of bed raised to the high-Fowler's position.

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? Select one: a. Assess the patient's airway. b. Remove the stinger from the site. c. Administer high-flow oxygen. d. Have the patient lie down.

The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance. The correct answer is: Assess the patient's airway.

In an industrial accident, a male client that weighs 155 lb. (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation calculated by the Parkland formula. Which finding demonstrates that the fluid calculated is the adecuate and is benefiting the client? Select one: a. A urine output volume of 40 ml in the last two hours b. Body temperature readings all within normal limits c. A weight gain of 4 lb. (2 kg) in 24 hours d. 50 ml of urine during the last sixty minutes

The main purpuse of fluid resuscitation is to replace lost volemia, stabilization of vital signs and normalization of urinary output (more than 30 ml/h). Weight gain suggests fluid volume excess, elevated temperature relates with the presence of infections. 40 ml of urine in two hours translate hemoconcentration and decreased diuresis. 50 ml in one hour is a normal urinary output. The correct answer is: 50 ml of urine during the last sixty minutes

A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client's health history would lead the nurse to consult with the provider over the choice of medication? Select one: a. 25-pack-year smoking history b. Previous peptic ulcer c. Drinking 3 to 5 beers a day d. Taking warfarin (Coumadin)

The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem. The correct answer is: Drinking 3 to 5 beers a day

One hour after admission to the postanesthesia care unit (PACU), the postoperative client has become very restless. What is the nurse's first action? Select one: a. Call the surgeon to assess the client. b. Assess the oxygen saturation level. c. Administer pain medication as ordered. d. Assess for bladder distention.

The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority. The correct answer is: Assess the oxygen saturation level.

A 9-year-old male presents with severe erythematous bullous lesions that are believed to be an adverse response to a medication. Which of the following is the most likely diagnosis? Select one: a. Stevens-Johnson syndrome b. Lupus erythematosus c. Pemphigus d. Acne vulgaris

The most common form of erythema multiforme in children and young adults is Stevens-Johnson syndrome.Pemphigus is not manifested by erythema.Acne is not manifested by erythema.Lupus erythematosus is not manifested by bullae. The correct answer is: Stevens-Johnson syndrome

When a patient presents at the emergency department for an allergic reaction, the nurse recognizes the most severe consequence of a type I hypersensitivity reaction is: Select one: a. Anaphylaxis b. Urticaria c. Antibody-dependent cell-mediated cytotoxicity (ADCC) d. Hives

The most rapid and severe immediate hypersensitivity type I reaction is anaphylaxis.Urticaria, or hives, is a dermal (skin) manifestation of allergic reactions.Hives and urticaria are similar responses.ADCC is a mechanism that involves natural killer (NK) cells. Antibodies on the target cell are recognized by Fc receptors on the NK cells, which release toxic substances that destroy the target cell. The correct answer is: Anaphylaxis

A patient is at risk for acid-base imbalance because of a chronic health problem. One of the nursing goals is to maintain the patient's arterial serum pH between Select one: a. 7.85 and 7.95. b. 7.35 and 7.45. c. 7.46 and 7.56. d. 7.70 and 7.80.

The normal arterial serum pH is between 7.35 and 7.45. The correct answer is: 7.35 and 7.45.

The nurse is assessing for clubbing of the fingernails and would expect to find: Select one: a. a nail base that feels spongy with an angle of the nail base of 150 degrees. b. curved nails with a convex profile and ridges across the nail. c. an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. d. a nail base that is firm and slightly tender.

The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy. The correct answer is: an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

A nurse receives a telephone laboratory report of a patient's serum electrolytes. Which laboratory value indicates that the patient has a normal sodium balance? Select one: a. 148 mEq/L b. 126 mEq/L c. 139 mEq/L d. 132 mEq/L

The normal range for serum sodium is 135 to 145 mEq/L. The correct answer is: 139 mEq/L

Before a client's surgery begins, the circulating nurse notes that the nurse anesthetist did not perform a surgical scrub before coming into the operating room. Which action by the circulating nurse is most appropriate? Select one: a. Proceed with positioning the client on the operating bed. b. Proceed with setting up the instruments to be used during surgery. c. Notify the nursing supervisor that sterile technique has been violated. d. Direct the nurse anesthetist to perform the surgical scrub immediately.

The nurse anesthetist does not need to perform a sterile scrub before the client's surgery is performed. The circulating nurse can proceed with positioning the client on the operating room bed. The correct answer is: Proceed with positioning the client on the operating bed.

Which nursing intervention takes priority for a client admitted with severe metabolic acidosis? Select one: a. Assess the client's strength in the extremities. b. Obtain a diet history for the past 3 days. c. Perform medication reconciliation. d. Initiate cardiac monitoring.

The nurse follows the ABCs and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest. Medication reconciliation should be performed as soon as possible; however, this client is at risk for cardiac and neurologic complications of acidosis. Starvation may precipitate ketosis/acidosis, but this is not the priority. The correct answer is: Initiate cardiac monitoring.

The nurse checking an IV fluid order questions its accuracy. What does the nurse do first? Select one: a. Contacts the health care provider who ordered it b. Contacts the pharmacy for clarification c. Asks the charge nurse about the order d. Starts the fluid as ordered, with plans to check it later

The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate. The correct answer is: Contacts the health care provider who ordered it

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? Select one: a. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. b. Wear gloves and gown when contact with body secretions or body fluids is expected. c. Carefully wash hands only when they are visibly soiled. d. Wear a mask with eye protection and perform proper handwashing.

The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile. The correct answer is: Wear gloves and gown when contact with body secretions or body fluids is expected.

Which precaution is best for the nurse to take to prevent the transmission of vancomycin resistant enterococcus (VRE) infection? Select one: a. Wear a mask and gloves when the client's body secretions are likely to be handled. b. Carefully wash hands and avoid use of alcohol based hand sanitizer. c. Wear gloves and gown when contact with body secretions or body fluids is expected. d. Wear a mask with eye protection and perform proper handwashing.

The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. Hands must be properly washed before and after any contact with the client with VRE. Alcohol-based hand rubs are effective for hand hygiene in the care of clients with VRE. It is not necessary to wear a mask when caring for clients with VRE infection. A mask and eye protection are not necessary to prevent transmission of VRE. The correct answer is: Wear gloves and gown when contact with body secretions or body fluids is expected.

A postsurgical client's urinary output via the Foley catheter is 30 mL in 3 hours. What is the nurse's first action? Select one: a. Weigh the client. b. Check the patency of the catheter. c. Assess the client's skin turgor. d. Increase the IV infusion rate.

The nurse should check to ensure that the client's catheter tubing is patent. If the catheter is patent, the nurse should increase the IV flow rate if there are orders to do so, or should call the surgeon to report the information and request more fluids. Assessing the skin turgor would give information on hydration status, but this would not be the first intervention. Weighing the client probably would not give relevant information related to this client because the concern has arisen in the last 3 hours. The correct answer is: Check the patency of the catheter.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? Select one: a. Provide a calm location for the family to cope and discuss needs. b. Provide privacy for law enforcement to interview the family. c. Do not allow visiting of the victims until the bodies are prepared. d. Call the hospital chaplain to stay with the family and pray for the deceased.

The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs. The correct answer is: Provide a calm location for the family to cope and discuss needs.

At the beginning of the shift, a patient's IV bag has 900 mL remaining. The IV fluid is running at 75 mL/hr. In 8 hours, there should be how many milliliters remaining in the IV bag? Select one: a. 150 b. 450 c. 600 d. 300

The nurse should multiply 75 mL/hr by 8 (the number of hours infusing for the shift), which yields a total shift infusion of 600 mL. Then she should subtract the 600 mL from the 900 mL that were present at the beginning of the shift to obtain 300 mL, the amount that should still remain. The correct answer is: 300

The nurse is caring for a client who will be having surgery with spinal anesthesia. The client says to the nurse, "I changed my mind-I don't want to be awake during surgery!" What is the nurse's best response? Select one: a. "The anesthesiologist has already determined this is best for your surgery." b. "I will call the anesthesiologist to come and talk to you." c. "It's too late to change now because all the equipment is in place." d. "Spinal anesthesia is safer than being put to sleep with general anesthesia."

The nurse should recognize the client's concerns and pass them on to the anesthesiologist. The nurse should not try to convince the client or to teach him or her at this time. The correct answer is: "I will call the anesthesiologist to come and talk to you."

A client voluntarily signed the operative consent form. What is the nurse's next action? Select one: a. Teach the client about the surgery. b. Sign under the client's name as a witness. c. Have family members witness the signature. d. Call for the physician to sign the form.

The nurse's signature as a witness indicates that the consent form was signed by the client voluntarily. None of the other steps are necessary. The correct answer is: Sign under the client's name as a witness.

A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety? Select one: a. Ensure the client is eating a high-fiber diet. b. Monitor the client's bowel function every shift. c. Assess and record the client's pain every 4 hours. d. Remove the old patch when applying the new one.

The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety. The correct answer is: Remove the old patch when applying the new one.

In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient? Select one: a. The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. b. The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly. c. The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. d. The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period.

The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs. The correct answer is: The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fiancé. Who should be asked to sign the surgery consent form? Select one: a. The patient's father b. The fiancé c. The physician, acting as a surrogate d. The son

The patient personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as he is the closest relative at the hospital. The fiancé is not legally related to him as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The physician would not sign if family members were available. The correct answer is: The son

The suprapubic area of a postoperative patient is distended. The patient states that he has not voided since surgery about 9 hours ago. The nurse's first action would be to: Select one: a. have the patient sit on the side of the bed and try to void. b. insert a catheter. c. prepare the patient to return to surgery. d. notify the physician.

The patient should be encouraged to try to void in a "natural" position before other measures are taken. The correct answer is: have the patient sit on the side of the bed and try to void.

A patient who has returned to the surgical nursing unit from the postanesthesia care unit is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is Select one: a. head of bed at 30 degrees with head and neck midline. b. supine. c. head of bed at 45 degrees with head and neck midline. d. side-lying.

The patient should be positioned on the side or with the head turned to the side to prevent aspiration. Maintaining an open airway is a priority measure. The correct answer is: side-lying.

An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? Select one: a. Hepatitis B vaccine b. Fresh frozen plasma c. Gamma globulin d. Corticosteroids

The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. The correct answer is: Gamma globulin

The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The patient verbalizes understanding of his disease process when he says Select one: a. "I will snack on raisins." b. "I can put catsup on my scrambled eggs." c. "I will avoid apricots." d. "I can snack on salted popcorn."

The patient will lose electrolytes, especially potassium, because he is on a diuretic; snacks such as raisins and apricots are rich in potassium. The correct answer is: "I will snack on raisins."

The spouse of a patient hospitalized with acquired immundeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia expresses her concerns about the possibility of acquiring this type of pneumonia. What statement by the registered nurse is correct? Select one: a. "You need to wear a regular surgical mask when you are near to your spouse" b. "Your spouse will be placed in droplet precautions to prevent the transmission of this infection" c. "You have to receive the pneumonia vaccine as soon as possible" d. "The risk if for your spouse of being infected with germs you could carry"

The patient with AIDS is immunosuppressed and is at risk of acquiring infections transmitted by other people. This patient should be in reverse isolation. P. jiroveci pneumonia is not transmitted by droplets and affects immunosuppressed individuals. The correct answer is: "The risk if for your spouse of being infected with germs you could carry"

A patient with cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? Select one: a. Consult with the doctor about increasing the MS Contin dose. b. Utilize distraction by talking about things the patient enjoys. c. Suggest the use of alternative therapies such as heat or cold. d. Administer the prescribed PRN immediate-acting morphine

The patient's pain requires rapid treatment and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies also may be needed, but the initial action should be to use the prescribed analgesic medications. The correct answer is: Administer the prescribed PRN immediate-acting morphine.

The nurse is caring for a diabetic patient who has chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. Which of these prescribed medications is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain? Select one: a. amitriptyline (Elavil) b. celecoxib (Celebrex) c. acetaminophen (Tylenol) d. aspirin (Ecotrin)

The patient's pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain. The correct answer is: amitriptyline (Elavil)

The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider? Select one: a. The patient's respiratory rate is 10 breaths/minute. b. The patient has a distended bladder and has not voided. c. The patient has not had a bowel movement for 3 days. d. The patient complains of nausea after eating.

The patient's respiratory rate indicates a need to decrease the PCA dose or change the medication in order to avoid further respiratory depression. The other information also may require intervention, but is not as urgent to report as the respiratory rate. The correct answer is: The patient's respiratory rate is 10 breaths/minute.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? Select one: a. The patient's capillary refill is less than 2 seconds. b. The patient has a raised red rash on the right shin. c. The patient ate two thirds of breakfast. d. The patient has fecal incontinence.

The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits. The correct answer is: The patient has fecal incontinence.

The nurse notes darker skin pigmentation in the skinfolds of a patient who has a body mass index of 40 kg/m2. Which action should the nurse take? Select one: a. Educate the patient about treatment of fungal infection. b. Discuss the use of drying agents to minimize infection risk. c. Instruct the patient about use of mild soap to clean skinfolds. d. Assess for other risk factors for metabolic syndrome.

The presence of acanthosis nigricans in skinfolds suggests metabolic syndrome and an increased risk for type 2 diabetes. The description of the patient's skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better. The correct answer is: Assess for other risk factors for metabolic syndrome.

A 30-year-old female complains of fatigue, arthritis, rash, and changes in urine color. Laboratory testing reveals anemia, lymphopenia, and kidney inflammation. Assuming a diagnosis of SLE, which of the following is also likely to be present? Select one: a. Antinuclear antibodies b. Anti-LE antibodies c. Antiherpes antibodies d. Anti-CMV antibodies

The presence of antinuclear antibodies is a diagnostic criterion for SLE.The presence of antinuclear antibodies is a diagnostic criterion for SLE. It would be positive LE.The presence of antinuclear antibodies is a diagnostic criterion for SLE, not antiherpes.The presence of antinuclear antibodies is a diagnostic criterion for SLE, not anti-CMV. The correct answer is: Antinuclear antibodies

A client will be undergoing palliative surgery. The client's daughter asks what this means. What is the nurse's best response? Select one: a. "There are fewer risks with this type of surgery." b. "The surgery must be performed immediately to save your father's life." c. "The surgery will relieve the symptoms but will not cure your father." d. "There is no guarantee of the outcome of the surgery."

The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life. The correct answer is: "The surgery will relieve the symptoms but will not cure your father."

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient? Select one: a. Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and decrease infection. b. Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection. c. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications d. Reduce smoking by 50% to prevent the development of pneumonia.

The reduction of smoking will enhance pulmonary function; in the preoperative period, patients who smoke should be urged to stop 4 to 8 weeks before surgery. The correct answer is: Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

In burn injury patients, the rule of nines and the Lund and Browder chart are used to estimate: Select one: a. Degree of systemic involvement b. Possibility of infection c. Total body surface area burned d. Depth of burn injury

The rule of nines estimates the total body surface area burned.The rule of nines estimates the total body surface area burned, not the depth of burn injury.The rule of nines estimates the total body surface area burned; the possibility of infection is 100%.The rule of nines estimates the total body surface area burned. It does not estimate the degree of systemic involvement. The correct answer is: Total body surface area burned

A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which of these prescribed medications will be best for the nurse to administer? Select one: a. immediate-release morphine 30 mg orally b. lorazepam (Ativan) 1 mg orally c. ibuprofen (Motrin) 400 to 800 mg orally d. amitriptyline (Elavil) 10 mg orally

The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. The Motrin and Elavil may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of anti-anxiety agents for pain control is inappropriate because this patient's anxiety is caused by the pain. The correct answer is: immediate-release morphine 30 mg orally

A client diagnosed with urinary tract infection has been prescribed oral trimethoprin sulfamethoxasol. Two days after initiated the therapy the client phones the registered nurse to report a painful rash with target shaped lesions and vesicles. The nurse should recommend: Select one: a. Discontinuation of the medication and visiting the emergency department b. Discontinuation of the medication and initiation of over the counter antihistaminic c. Discontinuation of the medication and changing to ciprofloxacin d. Discontinuation of the medication and application of hydrocortisone cream

The skin reaction is suggestive of Toxic Epidermal Necrolysis ( Steven Johnson Syndrome) and requires immediate medical attention The correct answer is: Discontinuation of the medication and visiting the emergency department

The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the: Select one: a. results of a computerized axial tomography scan. b. physical examination. c. patient's vital signs. d. subjective report.

The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot base the diagnosis of pain exclusively on physical assessment findings. The correct answer is: subjective report.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patient's signature on a consent form. Which comment by the patient would best indicate informed consent? Select one: a. "Because the physician isn't taking my ovaries, I'll still be able to have children." b. "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." c. "The physician is going to remove my uterus and told me about the risk of bleeding." d. "I know I'll be fine because the physician said he has done this procedure hundreds of times."

The surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the patient has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed. The correct answer is: "The physician is going to remove my uterus and told me about the risk of bleeding."

What recently learned information about a client who is scheduled to have surgery within the next 2 hours is the nurse certain to communicate to the surgical team? Select one: a. Taking 2000 mg of vitamin C each day b. An allergy to cats c. Hearing problem d. Consumption of a glass of wine 12 hours ago

The team will need to communicate with the client in the surgical holding area, in the operating room, and in the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed, so that team members can use alternative means to ensure accurate communication with the client. The correct answer is: Hearing problem

The nurse is assigned to care for four clients. Which client does the nurse assess first? Select one: a. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature b. Client with human immune deficiency virus (HIV) and Kaposi's sarcoma who has increased swelling of a sarcoma lesion on the right arm c. Client who has been admitted to receive a monthly dose of serum immune globulin to treat Bruton's agammaglobulinemia d. Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count

The temperature elevation of the client with a history of liver transplantation indicates that infection may be occurring; the client is at risk for overwhelming infection because of cyclosporine-induced immune suppression. Immediate assessment by the nurse is indicated. Information regarding the HIV-positive client with Kaposi's sarcoma and the client with Bruton's agammaglobulinemia indicates that these clients' physiologic statuses are relatively stable. It is not unusual for a client who is undergoing radiation to have a decreased total lymphocyte count. The correct answer is: Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's 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? Select one: a. Elevate the affected leg and apply ice. b. Try to place the affected leg in abduction. c. Prepare to administer pain medication. d. 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. The correct answer is: Assess neurovascular status in both legs.

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? Select one: a. Increased urinary output b. Increased rate and depth of respirations c. Increased thirst and hunger d. Decreased release of acids from the kidneys

This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide (Kussmaul respiration). Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The correct answer is: Increased rate and depth of respirations

The infection control nurse notices a rise in nosocomial infection rates on the surgical unit. Which action should the infection control nurse implement first? Select one: a. Tell the unit manager to decide on a corrective measure. b. Arrange to observe the staff at work for several shifts. c. Form a hospital-wide quality improvement project. d. Hold an in-service for the staff on the proper method of hand washing.

This is an action that will allow the infection control nurse to observe compliance with standard nursing practices such as hand washing. Once the nurse has attempted to determine a cause, then a corrective action can be implemented. The correct answer is: Arrange to observe the staff at work for several shifts.

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, what statement or question by the nurse is most appropriate? Select one: a. "I wish I could do more; is there anything I can get for you?" b. "Help me understand how pain is affecting you right now." c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question. The correct answer is: "Help me understand how pain is affecting you right now."

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

This patient has increased risk of a pathologic fracture with minimum trauma. Transferring clients is a nursing skill that is included in UAP education and scope of practice. Using a lift sheet by two people decrease the risk of trauma. Collaborating with the dietitian, evaluating the client's laboratory results, and implementing seizure precautions all require broader education and scope of practice and should be done by licensed nursing personnel. The correct answer is: Transferring the client from the bed to a stretcher using a lift sheet

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage Select one: a. II. b. I. c. III. d. IV.

This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle. The correct answer is: II.

The nurse applies antiembolism stockings to a client preoperatively. When the client says that they are uncomfortably tight, what is the nurse's best action? Select one: a. Remove the stockings for an hour to relieve the pressure. b. Pull the stockings down so that they are not constricting. c. Measure the client's calf to ensure that they are the correct size. d. Teach the client the purpose of wearing the stockings.

Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous return and prevent the client from developing venous thromboembolism (VTE). The nurse should not remove the stockings nor pull them down. The calf would have been measured before the stockings were obtained. The correct answer is: Teach the client the purpose of wearing the stockings.

A 4-month-old female develops white spots and shallow ulcers in her mouth. Her pediatrician diagnoses her with thrush. This condition is caused by: Select one: a. Escherichia coli b. Staphylococcal bacteria c. Streptococcal bacteria d. Candida albicans

Thrush is caused by Candida albicans. The correct answer is: Candida albicans

A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? Select one: a. "I have this ringing in my ears that just won't go away." b. "I seem to have lost my appetite, which is unusual for me." c. "I feel so foggy in the mornings and it takes me so long to wake up." d. "When I eat a meal that's high in fat, I get really nauseous."

Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia. The correct answer is: "I have this ringing in my ears that just won't go away."

A patient who has been receiving IV fluid therapy experiences an air embolus in the line. The nurse should immediately turn the patient onto the Select one: a. left side and raise the head of the bed. b. right side and raise the head of the bed. c. right side and lower the head of the bed. d. left side and lower the head of the bed.

To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The physician is notified immediately. The correct answer is: left side and lower the head of the bed.

The nurse is assessing for jaundice and notices yellowing at the corners of the sclera in an African-American client with suspected sickle cell anemia and hemolytic crisis. What does the nurse do next to confirm jaundice? Select one: a. Palpates the liver b. Request an order for hemoglobin c. Checks the hard palate mucosa d. Examines the client's hair

To assess dark-skinned clients for jaundice, check for a yellow tinge to the oral mucous membranes, especially the hard palate. The sclera in the corners of the eye can have a yellowish discoloration in normal individuals of this race. Although the liver is involved in jaundice, palpating it is not the nurse's next action. Examining the hair and evaluating hemoglobin are not indicated to determine jaundice. The correct answer is: Checks the hard palate mucosa

When assessing the quality of a patient's pain, the nurse should ask which question? Select one: a. "When did the pain start?" b. "What does your pain feel like?" c. "Is it a sharp pain or dull pain?" d. "Is the pain a stabbing pain?"

To assess the quality of a person's pain, have the patient describe the pain in his or her own words. The correct answer is: "What does your pain feel like?"

The nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion? Select one: a. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed b. Asks the client to both say and spell his or her full name and room number before starting the blood transfusion c. Ensures that also another qualified health care professional double checks the unit before administering d. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses. Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event. It requires a great amount of follow-up and often changing of policies to improve safety. The Joint Commission requires that the client provide two identifiers, but they are the name and date of birth or some other identifying data, depending on the facility; saying and spelling the name is only one identifier. Although a check is provided at the blood bank, this is not the one that is done before administration to the client. Clients do need to have normal saline running with blood, but this is not considered to be part of the safety check before administration of blood and blood products. The correct answer is: Ensures that also another qualified health care professional double checks the unit before administering

A patient scheduled for surgery has an order for a preoperative surgical skin prep. Which is the correct method to implement this procedure? Select one: a. Scrub surgical area for 1 minute with antibacterial solution. b. Rinse the area with clean cold water. c. Clip hair by moving away from the incision site. d. Clip large areas of hair at a time.

To perform a surgical preparation, clippers are used to clip the hair in a manner that moves away from the incision site. Small areas should be done at a time to avoid nicks, and the site is scrubbed with an antibacterial solution for 2 to 3 minutes, rinsed with clean warm water, and dried with gauze sponges. The correct answer is: Clip hair by moving away from the incision site.

The final stage of gout, characterized by crystalline deposits in synovial membranes, soft tissue and skin, is called: Select one: a. Tophaceous gout b. Monarticular arthritis c. Complicated gout d. Asymptomatic hyperuricemia

Tophaceous gout is a progressive inability to excrete uric acid, which expands the urate pool. Until urate crystal deposits (tophi) appear in cartilage, synovial membranes, tendons, and soft tissue.Tophaceous gout, not monarticular arthritis gout, is characterized by crystalline deposits.Asymptomatic hyperuricemia would not lead to crystalline deposits.Tophaceous gout, not complicated gout, is characterized by crystalline deposits The correct answer is: Tophaceous gout

The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? Select one: a. A patient with second-degree burns b. A patient with graft-versus-host disease after a recent bone marrow transplant c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient who has viral pneumonia

Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction. The correct answer is: A patient who is recovering from an anaphylactic reaction to a bee sting

When a nurse notices that a patient has type O blood, the nurse realizes that anti-_____ antibodies are present in the patient's body. Select one: a. A only b. B only c. A and B d. O

Type O individuals have both anti-A and anti-B antibodies.Type O individuals have both A and B antibodies.Type O individuals have both A and B antibodies.Type O individuals will have A and B antibodies, but not O. The correct answer is: A and B

A 16-year-old is bitten by a rabid dog while jogging in the park. Upon admission to the emergency department, the nurse will administer which of the following to help prevent infection? Select one: a. Immune globulin b. Cytotoxic T cells c. Macrophages d. Helper T cells

Unvaccinated individuals who are exposed to particular infectious agents often will be given immune globulins, which are prepared from individuals who already have antibodies against that particular pathogen.The patient would be given immune globulin, not cytotoxic T cells.The patient would be given immune globulin, not helper T cells.The patient would be given immune globulin, not macrophages. The correct answer is: Immune globulin

The nurse is caring for a patient with an incision. Which of the following actions would best indicate an understanding of medical and surgical asepsis? Select one: a. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing b. Donning sterile gown and gloves to remove the wound dressing c. Donning clean goggles, gown, and gloves to dress the wound d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis-sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site. The correct answer is: Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing

When assessing a patient's pain, the nurse knows that an example of visceral pain would be: Select one: a. second-degree burns. b. hip fracture. c. cholecystitis. d. pain after a leg amputation.

Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys. The correct answer is: cholecystitis.

A nurse is admitting a patient to the surgical unit from the postanesthesia care unit. The nurse should plan her workload to enable monitoring of vital signs and level of consciousness for this patient as frequently as every Select one: a. 30 minutes. b. 15 minutes. c. hour. d. 5 minutes.

Vital signs and other pertinent assessments are made as frequently as every 15 minutes for the first hour, then every 30 minutes for 2 hours, then every hour for 4 hours, then every 4 hours. The correct answer is: 15 minutes.

The nurse is caring for a client who has a sodium level of 128 mEq/L. As part of the care, the nurse will restrict which item for this client? Select one: a. Water b. Sport drinks as Gatorade c. Soups and breads d. Eggs and cheese products

Water restriction is an important part of the treatment plan of hyponatremia to prevent dilutional hyponatremia (water intoxication). Restriction of the other products which are rich in sodium is not indicated. The correct answer is: Water

Herpes zoster (shingles) is caused by the reactivation of varicella zoster. The virus resides in the dorsal root ganglia of sensory nerves. It is seen in the segment of the skin that is innervated by the infected nerve. A furuncle (boil) is a small lesion filled with pus and may have a pustular head. It involves the deeper portion of the follicle. Folliculitis is a superficial infection of the follicle in which hair growth is seen in the center of the lesion. Candidiasis is characterized by white, plaque-like lesions.

What does this image indicate? Select one: a. Furuncle b. Candidiasis c. Herpes zoster d. Folliculitis

A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? Select one: a. 325 cells/mm3 of blood b. 200 cells/mm3 of blood c. 75 cells/mm3 of blood d. 450 cells/mm3 of blood

When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS. The correct answer is: 200 cells/mm3 of blood

When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider? Select one: a. Lentigo (liver spots) are present on dorsal of both hands. b. Cherry hemangiomas are scattered on the client's back. c. A multicolored lesion is present on the client's thigh. d. The skin on the extremities is thin and dry

The client in the intensive care unit diagnosed with COPD has a Swan-Ganz mean pulmonary artery pressure of 35 mmHg. Which healthcare provider order would the nurse question? a.Administer IV normal saline at 100 mL/hr b.Provide supplemental oxygen per nasal cannula at 2 L/min c.Continuous telemetry monitoring with strips every 4 hours d.Administer a loop diuretic IV every six hours

a.Administer IV normal saline at 100 mL/hr Couldn't find rationale

The nurse is caring for a client after thoracentesis for malignant pleural effusion, from whom 3 liters of fluid were extracted. Which data require immediate intervention by the nurse? a.The client refuses to perform shoulder exercises b.The client complains of a sore throat and is hoarse c.The client has crackles that clear with cough d.The client is coughing up pink frothy sputum

d.The client is coughing up pink frothy sputum Pink, frothy sputum is emergent. Pt is drowning in their own fluids

The nurse cares for clients in the long-term care facility. A client is diagnosed with Legionnaires' disease. Which of the following actions by the nurse is MOST appropriate? A.Place the client on droplet precautions. B.Ask for maintenance on the institution's hot water tank. C.Use a surgical mask when working at less than 3-foot from patient. D.Place the client in a negative pressure room

2. Ask for maintenance on the institution's hot water tank. (caused by Legionella pneumophila , which is found in WARM STAGNANT WATER such as hot water tanks, is spread by aerosolized route from the environmental source to the client )LEGIONNAIRE'S dz- severe form of PNEUMONIA

Which body position simultaneously relieves pressure from both the sacrum and the trochanter? Select one: a. supine with HOB at 30o elevation b. 90-degree side-lying position c. 30-degree lateral position d. supine with HOB at 45o elevation

A 30-degree lateral position is the best way to relieve pressure from the sacrum and trochanter. If needed, use pillows or a foam wedge to help the patient maintain the proper position. Cushion pressure points, such as the knees or shoulders, as well. 90 o lateral position leaves pressure on trochanter 30o lateral position with cushion leaves no pressure on sacral or trochanter area The correct answer is: 30-degree lateral position

A patient will be receiving a blood transfusion. The nurse will need to use a Select one: a. Y administration set. b. piggyback set. c. controlled-volume set. d. primary infusion set.

A Y administration set is used to place the blood on one side and normal saline on the other. The correct answer is: Y administration set.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by Select one: a. Tertiary intention. b. Partial-thickness repair. c. Secondary intention. d. Primary intention

A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. The correct answer is: Primary intention

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? Select one: a. A 22-year-old with a painful and swollen right wrist b. A 60-year-old reporting difficulty swallowing and nausea c. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F d. A 45-year-old reporting chest pain and diaphoresis

A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. The correct answer is: A 45-year-old reporting chest pain and diaphoresis

The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client's fear of discovery by his family? Select one: a. "Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?" b. "It is your duty to protect your family members from getting AIDS." c. "Is there somewhere private in the home where we can go and talk?" d. "I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick."

A nonthreatening approach used initially to find out whether the client has informed family members or desires privacy is very important. The client has a right to privacy and can make the decision whether to post handwashing signs; caution signs invade the client's right to privacy. Protection from infection is important, but stating that the family members should know about the disease is not respectful of the client's right to privacy. The nurse suggesting that it is the client's responsibility to protect his or her family from getting AIDS is an intimidating statement. It is the client's right to make the decision whether to inform family members about his or her illness. However, this "nonaction" could be grounds for a lawsuit if the client were to infect someone inadvertently. The correct answer is: "Is there somewhere private in the home where we can go and talk?"

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: Select one: a. papule. b. wheal. c. nodule. d. bulla.

A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape due to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm. The correct answer is: papule.

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following? Select one: a. Palliative b. Laparoscopic c. Curative d. Diagnostic

A patient on hospice will undergo a surgical procedure only for palliative care to reduce pain, but it is not curative. The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. The excision of a tumor is classified as curative. This patient is not having the tumor removed, only the size reduced. The correct answer is: Palliative

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by Select one: a. Primary intention. b. Partial-thickness repair. c. Secondary intention. d. Tertiary intention.

A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. The correct answer is: Secondary intention.

The alarm of a client's pulse oxymeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first? A. Administer oxygen by face mask. B. Provide 100 % oxygen by nasal cannula C. Prepare patient for endotracheal intubation D. Repeat the O2 sat measurement in 10 minutes

A. administer oxygen by face mask Patients O2 is low so oxygen administration is the first action that should be taken. O2 sats can be reassessed after commencing oxygen therapy. There is no reason that this patient should be intubated. 100% oxygen is not possible through a nasal cannula; the maximum oxygen a nasal cannula can deliver is 44% oxygen or 6 liters.

A 4-month-old female is diagnosed with atopic dermatitis (AD). Which of the following assessment findings by the nurse will most likely support this diagnosis? Select one: a. White patches b. Blistering c. Dry, itchy skin d. Moist reddened skin

AD has a constellation of clinical features that include dry, sensitive, itchy, and easily irritated skin because the barrier function of the skin is impaired.Dry skin, not blistering, occurs in AD.Dry skin, not moist skin, occurs in AD.White patches are characteristic of other disorders, such as measles. The correct answer is: Dry, itchy skin

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? Select one: a. Symmetry of lesions b. Diameter less than 6 mm c. Border regularity d. Color variation

Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm. The correct answer is: Color variation

A patient who had a hysterectomy yesterday has been NPO. The physician has now ordered the patient's diet to be clear liquids. Before administering the diet, the nurse should check for: Select one: a. gag reflex. b. positive Homans' sign. c. feelings of hunger. d. bowel sounds.

Absence of bowel sounds would contraindicate a diet. The correct answer is: bowel sounds.

The health care provider writes orders for a client who is admitted with a serum potassium level of 6.9 mEq/L. What does the nurse implement first? Select one: a. Place the client on a cardiac monitor. b. Administer IV glucose with insulin. c. Administer sodium polystyrene sulfonate (Kayexalate) orally. d. Teach the client about foods that are high in potassium.

Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should be to place the client on a cardiac monitor. Then calcium gluconate, IV glucose with insulin, and sodium polystyrene sulfonate could be administered in this order. The correct answer is: Place the client on a cardiac monitor.

The nurse is using the Braden scale to assess a client's risk for developing a pressure ulcer and calculates a score of 7. The nurse should interpret that this client has which level of risk for development of pressure ulcers? Select one: a. Unlikely to develop pressure ulcers. b. Moderate risk. c. High risk. d. Low risk.

Braden scale below 9: high risk of developing pressure ulcer. See Braden scale (last slide PP) The correct answer is: High risk.

A 25-year-old paralyzed male develops a dermal pressure ulcer. When assessing the patient's skin, which finding is the first indication of this ulcer? Select one: a. Indurations b. Ulceration c. Whiteness d. Redness

The initial sign of a pressure ulcer is redness. The correct answer is: Redness

In which phase do blood vessels dilate to increase capillary permeability; this allows plasma and blood components to leak out into the area that is injured? Select one: a. First intention healing b. Hemostasis c. Inflammatory phase d. Proliferation phase

Inflammatory phase occurs immediately after hemostasis stops bleeding, and promotes the migration of leukocytes and inflammatory mediators to the site of injury. The correct answer is: Inflammatory phase

A 54-year-old female was recently diagnosed with degenerative joint disease. This condition is characterized by loss of: Select one: a. The joint capsule b. Articular cartilage c. The epiphyses d. Synovial fluid

Degenerative joint disease is caused by loss of the articular cartilage.Degenerative joint disease is caused by loss of the articular cartilage, not the epiphyses.Degenerative joint disease is caused by loss of the articular cartilage, not the synovial fluid.Degenerative joint disease is caused by loss of the articular cartilage, not the joint capsule. The correct answer is: Articular cartilage

A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? Select one: a. Cool joints with decreased range of motion b. Visible atrophy of the knee and shoulder joints c. Joint stiffness, especially in the morning d. Signs of systemic infection

In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool. The correct answer is: Joint stiffness, especially in the morning

A client is brought to the hospital unconscious and needs emergency surgery. The client's only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the client's emergent surgery? Select one: a. Obtain written consultation with two surgeons that the surgery is needed. b. Contact the family member by phone and obtain verbal consent with two witnesses. c. Proceed with surgery and have the family member sign the consent as soon as possible. d. Have the hospital administrator appoint a temporary legal guardian.

In the event that a family member cannot come to the hospital before the surgery needs to begin, verbal consent should be obtained over the phone with two witnesses. The correct answer is: Contact the family member by phone and obtain verbal consent with two witnesses.

A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? Select one: a. It is likely that her newborn will become infected with HIV unless she uses antiretroviral therapy (ART). b. Because she is at an early stage of HIV infection, the infant will not contract HIV. c. Most infants born to HIV-positive mothers are not infected with the virus. d. The antiretroviral medications used to treat HIV infection are teratogenic.

Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. The correct answer is: Most infants born to HIV-positive mothers are not infected with the virus.

In discoid lupus erythematosus, skin lesions may be accompanied by Raynaud phenomenon, which is manifested by: Select one: a. Arterial aneurysms b. Vasospasm in the extremities c. Bone deformities d. Venous thrombus

Raynaud phenomenon is manifested by vasospasm in the extremities The correct answer is: Vasospasm in the extremities

A patient has a disease state that results from the secretion of toxins by bacteria. Which medical diagnosis will the nurse see documented on the chart? Select one: a. Hepatitis b. Tetanus c. Smallpox d. Malaria

Some bacteria secrete toxins that harm individuals. For instance, specific bacterial toxins cause the symptoms of tetanus or diphtheria.Tetanus, not malaria, is due to toxin secretion.Tetanus, not smallpox, is due to toxin secretion.Tetanus, not hepatitis, is due to toxin secretion. The correct answer is: Tetanus

The assessment by the emergency department nurse most indicative that a burn patient might be at risk for respiratory impairment is: Select one: a. burns on the face and neck. b. flaring nares. c. sooty sputum. d. respiration of 18.

Sooty sputum is the most indicative. Facial burns and flaring nares are not conclusive in themselves. Respiration of 18 is normal. The correct answer is: sooty sputum.

The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing, which had no drainage on admission, now has serosanguineous drainage accumulating under the dressing. Which nursing action is most appropriate at this time? Select one: a. Make a note of the change on the worksheet to report it at the end of shift. b. Change the surgical dressing immediately to prevent infection. c. Outline the area of drainage with a pen and mark it with the date and time. d. Reinforce the dressing with clean gauze sponges and tape.

The area should be outlined, dated, and timed for future reference and comparisons. The correct answer is: Outline the area of drainage with a pen and mark it with the date and time.

The nurse is caring for a client who has had conscious sedation. What is the primary advantage of this type of anesthesia? Select one: a. The client is able to follow directions. b. The client can talk through the procedure. c. No defensive reflexes are lost. d. No respiratory support is needed.

The client undergoing a moderate sedation procedure will not need respiratory support; this is the first and foremost advantage of this kind of sedation. The client will be able to follow directions during the procedure, but maintaining his or her own airway and not requiring mechanical ventilation decrease potential complications. The correct answer is: No respiratory support is needed.

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? Select one: a. A superficial crater with partial thickness skin loss b. Intact skin with non-blanching erythema c. Full-thickness skin loss with yellowish bottom d. An ulcer covered with dark necrotic tissue

The correct answer is: A superficial crater with partial thickness skin loss

An older adult client is being positioned on the operating bed for surgery. Which action is the highest priority for the nurse? Select one: a. Ensuring that the head is elevated to working height b. Assessing skin condition for the need for additional padding c. Placing gel pads under the client's shoulders and head d. Placing a soft pillow between the client's knees

The older adult client needs to be assessed and skin integrity evaluated. Older adults are at higher risk and need increased precautions. The client may need pads under the shoulders and head and between the knees, but the nurse should assess all areas for the need for additional padding. Raising the bed is not a priority action and in fact might increase risk for the client. The correct answer is: Assessing skin condition for the need for additional padding

Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications? Select one: a. 19-year-old requiring a laparoscopy b. 10-year-old admitted for a tonsillectomy c. 89-year-old scheduled for a knee replacement d. 40-year-old requiring gallbladder surgery

The older client is at highest risk for postoperative complications. Older adults often have multiple medical conditions, take several medications, are slightly dehydrated, and may have cognitive or physical impairments that potentially could hinder their recovery from an operation. The correct answer is: 89-year-old scheduled for a knee replacement

Which action indicates to the operating room supervisor that the scrub nurse requires additional teaching about sterile technique? Select one: a. Sterile surgical supplies are placed in the center of the sterile field. b. The sterile saline bottle cap is placed in the center of the sterile field. c. The nurse disposes of any equipment packages that are in poor condition. d. A small amount of sterile saline is poured out before it is poured into the basin.

The outside of the bottle cap is not sterile and should not be placed on the sterile field. The other actions indicate good understanding of sterile technique. The correct answer is: The sterile saline bottle cap is placed in the center of the sterile field.

The nurse notes the unlicensed assistive personnel (UAP) tied a sheet around the agitated osteoporotic client in the chair so the client will not fall out. Which action should the nurse implement first? Select one: a. Assess the client's need for restraints and notify the healthcare provider for an order. b. Remove the sheet from the client immediately. c. Explain to the UAP the sheet is a form of restraint and cannot be tied around the client. d. Praise the UAP for being concerned about the safety of the client.

The nurse must remove the sheet since it is a restraint. There must be an HCP's order prior to restraining a client. The correct answer is: Remove the sheet from the client immediately.

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? Select one: a. Carefully wash hands when they are visibly soiled. b. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. c. Wear gloves and gown when contact with body secretions or body fluids is expected. d. Wear a mask with eye protection and perform proper handwashing.

Postoperative instructions must be modified for a patient with an intraocular lens implant. The nurse modifies postoperative care from that given most general surgery patients as follows: Select one: a. Early ambulation is not necessary. b. The dressing should be removed immediately on return to the surgical unit. c. Do not have this patient cough. d. The patient should not be allowed to have visitors.

There are a few instances in which coughing is contraindicated. They include surgeries for hernias, cataracts, and brain surgery. The correct answer is: Do not have this patient cough.

The bull's eye lesion correspond to erythema migrans, the rash that appears on the first stage of Lyme disease. In this stage IV penicillin is ordered to treat the infection. The correct answer is: Administered the ordered IV penicillin

The nurse observes the following skin lesion in a patient who reports recent visit to an area where Lyme disease is frequent: Which intervention is expected the nurse initiates as soon as possible? Select one: a. Apply permethrin lotion on all body surface b. Administered the ordered IV penicillin x c. Assess the patient for presence of Bell's palsy d. Prepare the patient for a skin biopsy

When obtaining the patient's signature on the operative consent form, the patient seems confused about the procedure to be performed. The appropriate response by the nurse is to: Select one: a. encourage the patient to ask his family what the physician told them. b. tell the patient to talk to the physician after he gets to the operating room. c. ask the patient what the physician told him and then call the physician if necessary. d. ask the patient to go ahead and sign the consent.

The patient may not understand some of the medical terms used by the physician and the nurse may be able to explain them. If the patient still needs further information, notify the physician. It is the physician's responsibility to explain the procedure and risks to the patient. The correct answer is: ask the patient what the physician told him and then call the physician if necessary.

A nurse is assisting in the transfer of a postoperative patient from the postanesthesia care unit to the surgical nursing unit. To ensure the safety of the patient, the nurse would: Select one: a. put the side rails up after moving the patient from the stretcher to the bed. b. uncover the patient before transferring from the stretcher to the bed. c. ask the patient to move from the stretcher to the bed. d. move the patient rapidly from the stretcher to the bed.

The patient will probably still be experiencing residual effects of anesthesia; the side rails should be up to prevent the patient from falling out of bed. The correct answer is: put the side rails up after moving the patient from the stretcher to the bed.

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patient's diagnosis of type 1 diabetes affect the care that the nurse plans? Select one: a. The nurse should initiate a subcutaneous infusion of long-acting insulin. b. The nurse should administer a bolus of dextrose IV solution preoperatively. c. The nurse should assess the patient's blood glucose levels vigilantly. d. The nurse should keep the patient NPO for at least 8 hours preoperatively.

The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively. The correct answer is: The nurse should assess the patient's blood glucose levels vigilantly.

In teaching a client about skin cancer prevention, which instruction does the nurse include? Select one: a. "Avoid sun exposure between 9 a.m. and 3 p.m." b. "If you feel you must tan, use a tanning bed." c. "Examine your skin quarterly for possible cancerous or precancerous lesions." d. "Wear dark color clothing to protect your skin from the sun."

The sun's rays are strongest between 9 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. Opaque clear color clothing should be worn to protect the skin from the sun. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided. The correct answer is: "Avoid sun exposure between 9 a.m. and 3 p.m."

The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse? Select one: a. Continue teaching the client about the surgery. b. Obtain informed consent from the client. c. Revise the teaching plan for the client. d. Notify the surgeon and document the finding.

The surgeon should be notified right away so that the client can be instructed about the surgery to be performed. The client cannot give informed consent unless he or she understands the procedure. The correct answer is: Notify the surgeon and document the finding.

A 3-year-old male develops tinea capitis after playing with the family dog. This infection is caused by a: Select one: a. Parasite b. Virus c. Fungus d. Bacterium

Tinea capitis is caused by a fungus.Tinea capitis is caused by a fungus, not bacteria.Tinea capitis is caused by a fungus, not a virus.Tinea capitis is caused by a fungus, not a parasite. The correct answer is: Fungus

An appropriate implementation for a patient with severe psoriasis who has a nursing diagnosis of "Disturbed body image related to skin lesions" would be: Select one: a. reassuring the patient of a quick remission. b. touching the patient often. c. prompt administration of PRN medications. d. reminding the patient to bathe often.

To touch, interact, and care for a disfigured patient attentively role-models acceptance. The correct answer is: touching the patient often.

The nurse is caring for a patient with an incision. Which of the following actions would best indicate an understanding of medical and surgical asepsis? Select one: a. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing b. Donning sterile gown and gloves to remove the wound dressing c. Donning clean goggles, gown, and gloves to dress the wound d. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing

When planning care for a male client with burns on the upper torso, singed nasal hair, and dry brassy cough, which nursing diagnosis should take the highest priority? Select one: a. Disturbed body image related to facial skin scarring b. Impaired gas exchange related to airway edema c. Impaired physical mobility related to the disease process d. Risk for infection related to breaks in the skin

When caring for a client with upper body burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. The other options may be appropriate, but don't command a higher priority than option A because they don't reflect immediately life-threatening problems. The correct answer is: Impaired gas exchange related to airway edema

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? Select one: a. At least 3 hours b. Less than 2 hours c. As long as the patient remains comfortable d. Not longer than 30 minutes

When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia. The correct answer is: Less than 2 hours

A client is having spinal anesthesia for knee surgery. Which statement by the client indicates a good understanding of this type of anesthesia? Select one: a. "I will have less risk of developing pneumonia after surgery." b. "I will be able to walk sooner after your surgery." c. "I won't have to worry about having an allergic reaction." d. "I will have less risk of bleeding with epidural anesthesia."

With epidural anesthesia, the client remains conscious, respiratory function is unaffected, and intubation is not necessary. This results in less risk for atelectasis or pneumonia after surgery. The correct answer is: "I will have less risk of developing pneumonia after surgery."

The nurse is caring for a client who will be undergoing emergency surgery as soon as possible. Which information is most important for the nurse to teach the client at this time? Select one: a. What to expect in the operating and recovery rooms b. How the surgery will be performed c. Complications that may occur after surgery d. Importance of early ambulation after surgery

With only a few minutes before surgery, the nurse should tell the client what to expect in the operating room and in the recovery room to minimize his or her anxiety. Although the other information is important, the nurse needs to start with what is vital for the client to know right now. The correct answer is: What to expect in the operating and recovery rooms

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply? Select one: a. Sterile petroleum gauze b. Povidone-iodine-soaked gauze c. Dry sterile dressing d. Moist, sterile saline gauze

Wound care basics are: sterility and the wound has to remain covered and moist to promote healing. The correct answer is: Moist, sterile saline gauze

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? Select one: a. Provide the patient with a pamphlet explaining the procedure. b. Call the physician to review the procedure with the patient. c. Explain the procedure clearly to the patient and her family. d. Have the patient sign the informed consent and place it in the chart.

While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. The consent formed should not be signed until the patient understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the patient about the surgical procedure, but will not substitute for the information provided by the physician. The correct answer is: Call the physician to review the procedure with the patient.

A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity does the nurse assign to an LPN/LVN working with this client? Select one: a. Teach the client about signs of incisional infection. b. Complete the written discharge instructions for the long-term-care facility. c. Instruct the client about how to do dressing changes. d. Apply an antibiotic ointment and place a sterile dressing on the incision

Wound care is included in practical nursing education. Client teaching and instruction and completing discharge teaching are more complex skills that are included in the RN scope of practice. The correct answer is: Apply an antibiotic ointment and place a sterile dressing on the incision.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: Select one: a. pruritus. b. xerosis. c. seborrhea. d. alopecia.

Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin. The correct answer is: xerosis.

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is especially important for infection control? a. The characteristics of the cough and expectorations b. The names of close friends and family members c. What medications have been prescribed and their side effects d. The address and name of the person from whom the client contracted TB

b. The names of close friends and family members

The nurse observes the unlicensed assistive personnel removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? a.Praise the UAP since this prevent the client from tripping on the oxygen tubing b.Place the oxygen back on the client while sitting in the BR and say nothing c.Immediately explain the UAP the oxygen should be left in place at all times if ordered d.Discuss the UAP action with the charge nurse so appropriate action can be taken

b.Place the oxygen back on the client while sitting in the BR and say nothing The nurse shouldn't correct the UAP in front of the patient. It may cause the patient to lose confidence in the staff.

A female patient is initiating anti TB treatment with combination of drugs. What recommendations should make the RN? a.You should use an oral contraceptive because some drugs are teratogenic b.Avoid driving because the risk of seizures induced by the treatment c.You will need a supplement of vitamin B while in treatment d.Use acetaminophen if you have fever higher that 100.4 oF e.Discoloration of urine and tears is expected f.You will need to check your liver enzymes periodically g.Arthralgia could be experienced while in treatment h.Vertigo and tinnitus are expected side effects and should not concern

c. You will need a supplement of vitamin B while in treatment e. Discoloration of urine and tears is expected f. You will need to check your liver enzymes periodically g. Arthralgia could be experienced while in treatment

A patient is arriving to ED with a positive AFB test. What should the nurse do first? a.Assess patient's vital signs and O2 saturation b.The nurse should put on a particulate respiratory mask c.The patient should be fit with a regular surgical mask d.The patient should be placed in a negative pressure examination room

c.The patient should be fit with a regular surgical mask

The nurse working on an infectious disease unit should assign which client to a room with negative airflow and should also require personnel to don a particulate respirator mask and observe airborne, as well as standard precautions when caring for this client? a. An older client with hemoptysis who is admitted from an extended care facility b. Twin siblings admitted with scarlet fever that is complicated with pneumonia c. A female adolescent admitted with bacterial meningitis and skin lesions d. A client with sputum cultures results positive for AFB

d. A client with sputum cultures results positive for AFB couldn't find rationale

When assessing a restless intubated client who is on a mechanical ventilator, the nurse auscultates breath sounds on the right side of the chest only. What action should the nurse implement next? a. Provide comfort and sedation for the client b. Mark the lip line on the tube with indelible ink c. Apply soft wrist restraints per protocol d. Reposition the depth of the endotracheal tube

d. Reposition the depth of the endotracheal tube couldn't find rationale

The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? a.Warfarin to the client with an INR of 1.8 b.ASA 81 mg to a patient with ischemic heart disease c.A calcium channel blocker to a client with BP 112/80 mmHg d.Hang the heparin infusion bag on a client with aPTT 85", control time 29"

d.Hang the heparin infusion bag on a client with aPTT 85", control time 29" A- Normal INR is below 1.1. An INR of 1.8 is high B- 81 mg of Aspirin is a normal dose for a patient with heart disease C- Calcium channel blockers are used to maintain BP low or normal in patients with hypertension D- If the control time of client receiving heparin is 29", the top limit of anticoagulation is 2.5 times this time. 29" x 2.5 is 72.5". The client's aPTT is 85": too much, no heparin.

The client is admitted to rule-out a diagnosis of severe acute respiratory syndrome (SARS). Which information is most important for the nurse to ask related to this diagnosis? a.Current prescription and OTC medication use b.Dates of and any complications associated with recent immunizations c.Any problems with recent use of blood products d.Recent travel to mainland China, Hong Kong or Taiwan

d.Recent travel to mainland China, Hong Kong or Taiwan

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? Select one: a. Chronic drainage of fluid through the incision site b. Protrusion of visceral organs through a wound opening c. Complaint by patient that something has given way d. Drainage that is odorous and purulent

occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent. The correct answer is: Complaint by patient that something has given way

A patient is receiving a medication via IV piggyback. What indicates the setup is incorrect? Select one: a. Secondary line clamp is open. b. Slide clamp near the insertion site is open. c. Primary line clamp is closed. d. Secondary bag is hung higher than the primary bag.

When a medication is given via piggyback setup, the secondary bag is hung slightly higher than the primary line and, when the secondary infusion finishes, the primary one takes over again; so all clamps (roller and slide) must be open for the setup to work properly. The correct answer is: Primary line clamp is closed.

A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of 100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse regulate the infusion? Select one: a. 15 b. 25 c. 17 d. 33

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