Medsurg 3 Final

Which preoperative teaching is most important for the nurse to include when completing laryngectomy education? 1 Establishing a means for communicating postoperatively 2 Explaining that there will be a feeding tube postoperatively 3 Demonstrating how to care for a permanent laryngeal stoma 4 Teaching how to cough to expectorate bronchial secretions effectively

Establishing a means for communicating postoperatively Communication is a priority; it facilitates interaction, limits anxiety, and promotes safety. A nasogastric tube can cause trauma to the suture lines; total parenteral nutrition may be used. Demonstrating how to care for a permanent laryngeal stoma is done postoperatively as the client begins to accept the laryngectomy. After a laryngectomy the client cannot cough; expectoration occurs through the stoma.

Which purpose of Buck traction would a nurse recall when caring for a client with an intertrochanteric fracture of the femur who is awaiting surgery? 1 Reduces the fracture 2 Immobilizes the fracture 3 Maintains abduction of the leg 4 Eliminates rotation of the femur

Immobilizes the fracture A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery, and Buck traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment and is not the purpose of Buck traction. External rotation of the femur may still occur with Buck traction.

Which rationale explains why a client with tuberculosis who is prescribed isoniazid would also be prescribed vitamin B6? 1 B6 improves the nutritional status of the client. 2 It enhances the tuberculostatic effect of isoniazid. 3 B6 accelerates the destruction of dormant tubercular bacilli. 4 It counteracts the peripheral neuritis that isoniazid may cause.

It counteracts the peripheral neuritis that isoniazid may cause.

When auscultating a client's heart, the nurse understands that the first heart sound is produced by the closure of which valves? 1 Mitral and tricuspid 2 Aortic and tricuspid 3 Mitral and pulmonic 4 Aortic and pulmonic

Mitral and tricuspid Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). Aortic and tricuspid valves and mitral and pulmonic valves do not close simultaneously. Aortic and pulmonic valves are the semilunar valves; closure of these valves produces the second heart sound (S2).

Which finding would a nurse find inconsistent when monitoring a client with renal failure for signs of fluid excess? 1 Increased weight 2 Distended neck veins 3 Orthostatic hypotension 4 Abnormal breath sounds

Orthostatic hypotension Hypertension (not hypotension) is an indicator of fluid volume excess. Fluid excess causes weight gain. One liter of water weighs approximately 2.2 lb. Fluid excess increases the intravascular volume leading to jugular vein distention. Fluid excess causes fluid in the alveoli that leads to crackles, which are a sign of pulmonary edema.

Which finding indicates that sodium polystyrene sulfonate (Kayexalate) administered to a client with chronic renal failure is effective? 1 Constipation 2 Improved mental status 3 Sodium increases to 137 mEq/L 4 Potassium decreases to 4.2 mEq/L

Potassium decreases to 4.2 mEq/L This resin exchanges sodium ions for potassium in the large intestine to lower the serum potassium level. A value of 4.2 mEq/L is in the expected range for potassium. Frequent, loose stools is a common side effect. Mental status improvement is not a therapeutic effect of the drug. Sodium retention is an adverse effect. A value of 137 mEq/L is in the expected range for sodium.

Which student action requires intervention by the educator when tracheal suctioning is performed? 1 Maintains a sterile field 2 Applies suction during insertion of the catheter 3 Preoxygenates with 100% oxygen for 1 minute 4 Tests suction pressure at 100 mm Hg before inserting catheter

Applies suction during insertion of the catheter Suction should be applied during withdrawal, not insertion, of the catheter. A sterile field is required for tracheal suctioning, but not oral suctioning. Preoxygenation will be completed for 30 seconds to 3 minutes. Pressure must be tested before suctioning and be within the range of 80 to 120 mm Hg.

Which disorder of the musculoskeletal system is illustrated in the image? 1 Osteoporosis 2 Osteoarthritis 3 Rheumatoid arthritis 4 Ankylosing spondylitis

Rheumatoid arthritis

Which statement defines phantom limb pain? 1 Pain or discomfort in a body part that has been replanted 2 Sharp, burning sensation indicating the need for amputation 3 Discomfort or pain in the unaffected limb 4 Sensation of pain that feels like it is coming from the amputated body part

Sensation of pain that feels like it is coming from the amputated body part

Which statement indicates the client needs further teaching regarding taking warfarin and food selection? 1 "Eggs provide a good source of iron, which is needed to prevent anemia." 2 "Yellow vegetables are high in vitamin A and should be included in the diet." 3 "Milk and other high-calcium dairy products are necessary to counteract bone density loss." 4 "Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting."

"Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting." Foods high in vitamin K should be avoided because vitamin K is part of the body's blood clotting mechanism and will counter the effects of warfarin. Foods containing protein and iron are permitted because they are unrelated to blood clotting. Foods containing vitamin A are permitted because vitamin A is unrelated to blood clotting. Foods containing calcium are permitted because calcium is unrelated to blood clotting.

Which statement by a client with tuberculosis on a protocol that includes rifampin (RIF) indicates that the teaching about rifampin was effective? 1 "I need to drink a lot of fluid while I take this medication." "I can expect my urine to turn orange from this medication." 3 "I should have my hearing tested while I take this medication." 4 "I might get a skin rash because it is an expected side effect of this medication."

"I can expect my urine to turn orange from this medication." Rifampin (RIF) causes body fluids, such as sweat, tears, and urine, to turn orange. It is not necessary to drink large amounts of fluid with this drug as it is not nephrotoxic. Damage to the eighth cranial nerve is not a side effect of rifampin. It is a side effect of streptomycin sulfate, which is sometimes used to treat tuberculosis. A skin rash is not a side effect of rifampin.

Which statement regarding rheumatoid arthritis (RA) is true? 1 "It is a systemic condition." 2 "It affects only the hips and hands." 3 "It involves bone spur formation." 4 "It affects males and females equally."

"It is a systemic condition." RA is a systemic condition that involves inflammation of synovial membranes and destruction of bones, ligaments, tendons, cartilage, and joint capsules. RA affects a number of joints, including the wrists, knees, and knuckles. Osteoarthritis involves bone spur formation. Females are more likely to be affected by RA than are males, at a ratio of 3:1.

Which action will the nurse include in the plan for care for a client after a bronchoscopy examination? 1 Check for the gag reflex. 2 Send the client for a chest x-ray examination. 3 Assess breathing every 30 minutes. 4 Have the client avoid the Valsalva maneuver.

Check for the gag reflex. After bronchoscopy, the nurse will assess for return of the gag reflex before providing anything by mouth. A chest x-ray examination is not needed after bronchoscopy but would be prescribed after diagnostic procedures such as thoracentesis. Breathing should be assessed at least every 15 minutes for 2 hours after bronchoscopy. The Valsalva maneuver is safe to perform after bronchoscopy.

Which goal of therapy would the nurse anticipate when administering allopurinol to a client with gout? 1 Increase bone density 2 Decrease synovial swelling 3 Decrease uric acid production 4 Prevent crystallization of uric acid

Decrease uric acid production Allopurinol interferes with the final steps in uric acid formation by inhibiting the production of xanthine oxidase. This drug prevents the formation of uric acid and does not affect bone density. Allopurinol has no effect on the swelling of the synovial membranes. This medication prevents the synthesis of uric acid, not its crystallization.

Which goal is the priority for a client with asthma who is being discharged from the hospital? 1 Is able to obtain pulse oximeter readings 2 Demonstrates use of a metered-dose inhaler 3 Knows the health care provider's office hours 4 Can identify the foods that may cause wheezing

Demonstrates use of a metered-dose inhaler Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have before discharge. Pulse oximetry is rarely conducted in the home; home management usually includes self-monitoring of the peak expiratory flow rate. Although knowing the health care provider's office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Not all asthma is associated with food allergies.

Which laboratory result would be of concern to the nurse for a client receiving digoxin therapy for cardiomyopathy? 1 Hypokalemia 2 Hypernatremia 3 Increased hematocrit 4 Increased white blood cell (WBC) count

Hypokalemia If a client has hypokalemia, this increases his or her risk for digoxin toxicity. This occurs through binding Na+, K+, and ATPase. This process enhances the chance for toxicity. Hypernatremia is not related to digoxin therapy. It typically results from dehydration such as in the use of diuretics. An increased hematocrit is not related to digoxin therapy. It indicates dehydration or polycythemia vera (this causes the body to produce too many red blood cells [RBCs]). An increased WBC count typically is related to infection, not digoxin toxicity.

Which response by the nurse is appropriate for a client with emphysema who is questioning why he or she has a barrel chest? 1 "The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size." 2 "This is caused by large amounts of mucus in your lungs from inflammation." 3 "Your airways are narrowed in response to stimuli in your environment." 4 "The left side of your heart is weak and is causing fluid in your lungs."

"The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size." Emphysema is a form of chronic obstructive pulmonary disease (COPD). It causes a decrease in lung elasticity due to chronic irritation primarily from smoking. The loss of elasticity leads to overstretching of the alveoli and hyperinflation of the lungs. Chronic bronchitis also is a form of COPD. It causes large amounts of thick mucus to form from chronic inflammation primarily due to smoking. Hyperresponsiveness to environmental stimuli and the resultant bronchospasm and edema are related to asthma. Right-sided heart failure can result from COPD but is not the cause of the barrel chest. Left-sided heart failure causes pulmonary edema but is not the cause of the barrel chest.

Which indicator would the nurse expect in a client with end-stage renal disease? Select all that apply. One, some, or all responses may be correct. 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypertension 5 Polycythemia

Azotemia Hypertension Azotemia is an increase in nitrogenous waste in the blood and is common in end-stage renal disease. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the rennin-angiotensin-aldosterone system. Excessive nephron damage in end-stage renal disease causes oliguria not polyuria. Excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not end-stage renal disease. Anemia (not polycythemia) occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.

Which action by the nurse is the priority when excessive bubbling is observed in the water-seal chamber of a chest tube? 1 Strip the chest tube catheter. 2 Check the system for air leaks. 3 Decrease the amount of suction pressure. 4 Recognize that the system is functioning correctly.

Check the system for air leaks. Excessive bubbling indicates an air leak, which must be eliminated to permit lung expansion. Striping the chest tube catheter is contraindicated because it can increase the pressure in the pleural space and cause a pneumothorax. Decreased suction pressure results in limiting bubbling in the suction control, not the water-seal chamber. Excessive bubbling in the water-seal chamber is not expected; the system is malfunctioning.

Which responses would the nurse expect a client to exhibit when a therapeutic effect of digoxin is achieved? 1 Diuresis and decreased pulse rate 2 Increased blood pressure and weight loss 3 Regular pulse rhythm and stable fluid balance 4 Corrected heart murmur and decreased pulse pressure

Diuresis and decreased pulse rate Digoxin slows the heart rate, which is reflected in a slowing of the pulse; it also increases kidney perfusion, which promotes urine formation, resulting in diuresis and decreased edema. Digoxin would decrease, not increase, the blood pressure; digoxin does promote weight loss through diuresis. Although digoxin produces diuresis as a result of improved cardiac output, which increases fluid output, it would not regulate an irregular pulse. Digoxin would not correct a heart murmur or decrease pulse pressure.

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1 Apply a thoracic binder for support. 2 Encourage coughing and deep breathing. 3 Defer pain medication the first day after injury. 4 Position the client face down on a soft mattress.

Encourage coughing and deep breathing. Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and help motivate the client to cough and deep breathe. The prone position may diminish breathing for both lungs and is contraindicated.

Which response would the nurse expect when caring for a client receiving furosemide (Lasix) to relieve edema? 1 Retention of sodium ions 2 Negative nitrogen balance 3 Excessive loss of potassium ions 4 Increase in the urine specific gravity

Excessive loss of potassium ions Furosemide is a potent diuretic used to provide rapid diuresis. It acts in the loop of Henle and causes depletion of electrolytes such as potassium and sodium. Furosemide inhibits the reabsorption of sodium. Furosemide does not affect protein metabolism. The specific gravity of the fluid more likely will be low with edema.

Which sign is common for early laryngeal cancer? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness

Hoarseness Hoarseness is caused by the inability of the vocal cords to move adequately during speech when a tumor exists. Aphasia refers to an expressive or receptive communication deficit as a result of cerebral disease; it is not related to laryngeal cancer. Dyspnea is a late, not early, adaptation that occurs with laryngeal cancer when a tumor is large enough to obstruct air flow. Dysphagia is a late, not early, adaptation that occurs when the tumor is large enough to compress the esophagus.

Which manifestation is associated with osteoarthritis? 1 Inflammation of the big toe 2 Pain and stiffness of the joints 3 Tophi around the rim of the ear 4 Generalized achiness in the lower back

Pain and stiffness of the joints Pain and stiffness of the joints is a clinical manifestation of osteoarthritis. Inflammation of the big toe and the appearance of tophi around the rim of the ear are clinical manifestations of gout. Generalized achiness of the lower back is a clinical manifestation of fibromyalgia syndrome.

Which test result would the nurse anticipate when reviewing the laboratory reports of a client with end-stage renal disease? 1 Arterial pH 7.5 2 Hematocrit of 54% 3 Creatinine of 1.2 mg/dL 4 Potassium of 6.3 mEq/L

Potassium of 6.3 mEq/L Clients with end-stage renal disease have impaired potassium excretion so the nurse should anticipate a potassium level more than the expected range of 3.5 to 5 mEq/L. Clients with end-stage renal disease usually have a serum pH that is less than 7.35 due to metabolic acidosis. A pH of 7.5 that exceeds the expected range of 7.35 to 7.45 is not anticipated. Clients with end-stage renal disease have decreased erythropoietin which leads to decreased red blood cell production and hematocrit (HCT). A hematocrit of 54% exceeds the expected range which is 42% to 52% for males and 35% to 47% for females. Clients with end-stage renal disease have a decreased ability to eliminate nitrogenous wastes leading to increased creatinine levels. A creatinine level of 1.2 mg/dL is within the expected range of 0.7-1.4 mg/dL and therefore is not anticipated.

Which reason would the nurse give for why women are at a greater risk than men for contracting a urinary tract infection? 1 Altered urinary pH 2 Hormonal secretions 3 Juxtaposition of the bladder 4 Proximity of the urethra to the anus

Proximity of the urethra to the anus Because a woman's urethra is closer to the anus than a man's is, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in women and men.

Which complication is most common after hip surgery? 1 Pneumonia 2 Hemorrhage 3 Wound infection 4 Pulmonary embolism

Pulmonary embolism A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow. The occurrence of pneumonia is rare because of early activity after surgery. In addition, the operative area is not in proximity to the diaphragm and lungs; therefore, it does not impede deep breathing. Postoperative hemorrhage with hip surgery is rare because bleeding at the operative site is not covert. The incidence of wound infection is no greater than with other postoperative clients.

Which indicator would the nurse use to determine effectiveness after administration of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels

Relief of anginal pain Cardiac nitrates relax smooth muscles of the coronary arteries. They dilate and deliver more blood to heart muscle leading to relief of ischemic pain. Cardiac output may improve because of improved oxygenation of the myocardium, but improved cardiac output is not a basis for evaluating the drug's effectiveness. Dilation of blood vessels and a subsequent drop in blood pressure may occur, but decreased blood pressure is not a basis for evaluating the drug's effectiveness. Superficial vessels dilate and lower the blood pressure creating a flushed appearance, but dilation of superficial blood vessels is not a basis for evaluating the drug's effectiveness.

Which nursing consideration is the priority for a client recently involved in a motor vehicle accident (MVA) who has the following arterial blood gas results? pH 7.21 PaCO2 63 HCO2 24 PaO2 74 1 Urinary output 2 Respiratory quality 3 Pedal pulse strength 4 Areas of laceration

Respiratory quality The client is experiencing respiratory acidosis; the assessment of respiratory quality, including depth and rhythm, would be the priority assessment. Trauma nursing follows ABCDE: Airway, Breathing, Circulation, Disability, and Exposure. Urinary output is important to assess in the client who experienced trauma; however, this is not the priority nursing assessment. Peripheral pulse strength is also important but is not the priority assessment. Lacerations must be assessed and cared for, but unless the client is hemorrhaging, the nurse would not consider this the priority assessment.

Which symptom is the most important to report if a client has a history of pneumothorax? 1 Substernal chest pain 2 Episodes of palpitation 3 Severe shortness of breath 4 Dizziness when standing up

Severe shortness of breath Severe shortness of breath may indicate a recurrence of the pneumothorax because one lung is unable to meet the oxygen demands of the body. A pneumothorax causes sharp chest pain on the involved side, not substernally. Usually palpitations reflect a cardiac, not a respiratory, problem. Dizziness when standing up is not specific to a pneumothorax; this is orthostatic hypotension, which may be related to a variety of medical problems.

Which information would a nurse include when teaching a client who is to begin continuous ambulatory peritoneal dialysis (CAPD)? 1 Peritoneal dialysis is done in an ambulatory care clinic. 2 Hemodialysis and peritoneal dialysis are provided continuously. 3 The peritoneal membrane allows passage of toxins into the dialysate. 4 A quarter of a liter of dialysate is maintained inter- and intraperitoneally.

The peritoneal membrane allows passage of toxins into the dialysate. Dialysate is introduced into the peritoneal cavity where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane. The client can dialyze alone in any location without the need for machinery and continuous technical supervision. Hemodialysis is not necessary with this procedure. Each exchange involves 2 to 3 L of dialysate intraperitoneally (not interperitoneally) for a specified time (dwell time) before being drained.

Which crutch-walking technique would the nurse reinforce when a client who had knee surgery returns from physical therapy? 1 Two-point gait 2 Four-point gait 3 Three-point gait 4 Swing-through gait

Three-point gait The three-point gait requires arm strength and is used when a limb cannot bear weight. The affected leg and crutches are advanced together, and the strong leg swings through. Two- and four-point gaits require weight-bearing on both feet. Swing-through does not simulate ambulation and is not appropriate for this client.

Which diagnostic tests would the nurse expect to be prescribed to confirm diagnosis of a urinary tract infection in a client recovering from deep partial-thickness burns who develops chills, fever, flank pain, and malaise? 1 Urinalysis and urine culture and sensitivity 2 Cystoscopy and bilirubin level 3 Creatinine clearance and albumin/globulin (A/G) ratio 4 Specific gravity and pH of the urine

Urinalysis and urine culture and sensitivity The client's manifestations may indicate a urinary tract infection, and a culture of the urine will identify the microorganism. A cystoscopy is too invasive as a screening procedure. Altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function and A/G ratio reflects liver function. An increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine and are associated with urinary tract infection, but it will not identify the causative organism.

Which action by a 70-year-old female would limit further progression of osteoporosis? 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk and milk products

Taking supplemental calcium and vitamin D Research demonstrates that postmenopausal women require at least 1500 mg of calcium a day. This is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis and does not provide vitamin D unless the food is fortified. Calcium absorption is impeded when large amounts of magnesium are present because magnesium and calcium absorption are competitive. Vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

Which blood level would the nurse expect will increase first in a myocardial infarction? 1 Alanine aminotransferase (ALT) 2 Serum aspartate aminotransferase (AST) 3 Total lactate dehydrogenase (LDH) 4 Troponin T (cTnT)

Troponin T (cTnT) Troponin T has an extraordinarily high specificity for myocardial cell injury. Cardiac troponins elevate sooner and remain elevated longer than many of the other enzymes that reflect myocardial injury. ALT is found predominantly in the liver and is found in lesser quantities in the kidneys, heart, and skeletal muscles. It is primarily used to diagnose and monitor liver, not heart disease. AST (serum glutamic-oxaloacetic transaminase, SGOT) is elevated 8 hours after a myocardial infarction. Total LDH levels elevate 24 to 48 hours after a myocardial infarction.

Which statement to the nurse teaching a client scheduled for a kidney transplant about the need for immunosuppressive medications indicates understanding of the teaching? 1 "I must take these medications for the rest of my life." 2 "I must take these medications until the surgery is over." 3 "I must take these medications until the anastomosis heals." 4 "I must take these medications during the intraoperative period."

"I must take these medications for the rest of my life." These drugs must be taken continuously to prevent rejection of the transplanted organ. The danger of rejection always exists. The client must take the medications longer than after the surgery or until the anastomosis heals or during the intraoperative period

Which response would the nurse give to a client who asks what does a positive PPD test and a negative chest x-ray mean, in relation to his or her tuberculosis (TB) exposure? 1 "I will teach you how to monitor for signs and symptoms of developing TB." 2 "You will require two chest x-rays per year to rule out active TB." 3 "I need to perform a repeat PPD test." 4 "You will need to stop working for 6 months of therapy."

"I will teach you how to monitor for signs and symptoms of developing TB." A client with TB without signs or symptoms of the disease is unlikely to have active TB. The client does have a latent infection of TB, and the disease can develop if he or she becomes immunocompromised. Therefore, the client needs to be taught about the signs and symptoms of the disease. The signs and symptoms are productive cough for 3 or more weeks, unintentional weight loss, and weakness. A repeat chest x-ray is only needed if the client develops signs or symptoms of active TB. A repeat PPD test is unnecessary. This test has already demonstrated client exposure. A negative chest x-ray indicates that the client does not have active disease and is not infectious. Therefore, the client can continue to work.

Which client statement indicates an understanding of the nurse's instructions regarding a Holter monitor? 1 "The only times the monitor should be taken off is for showering and sleep." 2 "The monitor will record my activities and symptoms if an abnormal rhythm occurs." 3 "The results from the monitor will be used to determine the size and shape of my heart." 4 "The monitor will record any abnormal heart rhythms while I go about my usual activities."

"The monitor will record any abnormal heart rhythms while I go about my usual activities." The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

Which condition occurs in part as a result of deficiencies in vitamin D and calcium? 1 Osteoporosis 2 Osteoarthritis 3 Ankylosing spondylitis 4 Fibromyalgia syndrome

Osteoporosis Osteoporosis makes bones brittle and fragile as a result of deficiencies in vitamin D and calcium. Osteoarthritis involves degeneration of cartilage as a result of bone spur formation and wear and tear. Ankylosing spondylitis is marked by positive results on HLA-B27 marker testing, a family history of the disease, and gastrointestinal manifestations. Fibromyalgia syndrome is associated with tenderness at multiple characteristic sites.

Which characteristic would the nurse assess for in each specimen of urine for in a client with a urinary tract infection? 1 Clarity 2 Viscosity 3 Glucose level 4 Specific gravity

Clarity Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Viscosity is a characteristic that is not measurable. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.

Which nursing action would the nurse prioritize before administering digitalis to the client? 1 Administer medication with a full glass of water 2 Inform the client dizziness is common with digitalis 3 Hold digitalis if heart rate is less than 60 beats per minute 4 Do not administer if heart rate is greater than 100 beats per minute

Hold digitalis if heart rate is less than 60 beats per minute The nurse should obtain and record the apical pulse for 1 full minute prior to administering digitalis. Digitalis should be held if the apical pulse is less than 60 beats per minute. Dizziness is not a common adverse reaction the client may experience with digitalis therapy. Administering the medication with a full glass of water is important. However, taking the apical pulse before administration is the priority. Digitalis is a cardiac glycoside intended to slow and strengthen myocardial contraction. If the client's heart rate is greater than 100 beats per minute, the drug would be administered as ordered.

Which action would be a part of the nurse's plan of care to prevent future development of renal calculi in a client with ureteral colic? 1 Interventions to decrease the serum creatinine level 2 Excluding milk products from the diet 3 Instructing the client to drink 8 to 10 glasses of water daily 4 A goal of 2000 mL/24 hours urinary output

Instructing the client to drink 8 to 10 glasses of water daily Increasing fluid intake dilutes the urine and crystals are less likely to coalesce and form calculi. An elevated serum creatinine has no relationship to the formation of renal calculi. Calcium restriction is necessary only if calculi have a calcium phosphate or calcium oxalate basis. Producing only 2000 mL of urine per 24 hours is inadequate as urine output should be maintained at 3000 to 4000 mL to limit calculus formation.

Which clinical finding would the nurse expect when completing the admission assessment on a client admitted with an abdominal aortic aneurysm and surgery scheduled in the morning? 1 Signs of shock 2 Visible peristaltic waves 3 Radiating abdominal pain 4 Pulsating abdominal mass

Pulsating abdominal mass As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Signs of shock are not definitive for an abdominal aortic aneurysm unless the aneurysm ruptures. Visible peristaltic waves are associated with an intestinal obstruction. Radiating abdominal pain is not definitive for an abdominal aortic aneurysm.

What is the client experiencing when blood gases indicate a pH level of 7.30, partial pressure of oxygen (PO2) at 60 mm Hg, partial pressure of carbon dioxide (PCO2) at 55 mm Hg, and a bicarbonate (HCO3) level of 23 mEq/L? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis

Respiratory acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), hemoglobin (Hgb), and hematocrit (Hct) are related to anemia.

Which part of the skeleton is categorized as axial? Select all that apply. One, some, or all responses may be correct. 1 Skull 2 Sternum 3 Vertebrae 4 Pelvic girdle 5 Shoulder girdle

Skull Sternum Vertebrae The skeleton is divided into the axial and appendicular skeletons. The axial skeleton includes the skull, sternum, and vertebrae. The appendicular skeleton includes the pelvic and pectoral (shoulder) girdles. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options are likely related to the situation, but only some of the options will be correct.

How would the nurse position a client with epistaxis? 1 Supine 2 Side-lying 3 Upright leaning forward 4 Sitting with the head tipped backward

Upright leaning forward A client with a nosebleed should be positioned upright leaning forward to prevent aspiration and decrease blood flow to the nose. The supine position increases the possibility of aspiration or swallowing blood. The side-lying position will increase blood flow to the nose more than sitting upright and may increase aspiration risk. Having the head tipped backward increases the possibility of aspiration or swallowing blood.

Which indicator of a urinary tract infection (UTI) would the nurse provide as part of the discharge instructions to a male client after ureterolithotomy with a history of recurrent UTIs? 1 Urgency or frequency of urination 2 The inability to maintain an erection 3 Pain radiating to the external genitalia 4 An increase in the alkalinity of the urine

Urgency or frequency of urination Urgency or frequency of urination occur with a urinary tract infection because of bladder irritability. Burning on urination and fever are additional signs of a UTI. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus and not an infection. An increase in alkalinity or acidity of urine is not a sign of a UTI.

Which action is important for the nurse to implement in a client with an indwelling urinary catheter when irrigating the bladder? 1 Use sterile equipment. 2 Instill the fluid under high pressure. 3 Warm the solution to body temperature. 4 Aspirate immediately to ensure return flow.

Use sterile equipment. The bladder is a sterile body cavity. When introducing a solution/catheter surgical asepsis is required. Excessive pressure can traumatize the lining of the urinary tract. The solution generally is administered at room temperature. Aspirating immediately to ensure return flow is done if the fluid does not return by gravity. The negative pressure exerted during aspiration may cause trauma.