Midterm

Cystic fibrosis is a condition passed on through which type of inheritance? A) Autosomal recessive B) Autosomal dominant C) X-linked recessive D) Multifactorial

A) Autosomal recessive Cystic fibrosis is an autosomal recessive inherited condition. Huntington disease is an example of an autosomal dominant inherited condition. Hemophilia is an X-linked recessive inherited condition. Cleft lip is a multifactorial inherited condition.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A) First intention B) Second intention C) Third intention D) Fourth intention

A) First intention When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes A) Gastroesophageal reflux disease (GERD) B) Chronic obstructive pulmonary disease (COPD) C) Congestive heart failure (CHF) D) Respiratory failure (RF)

A) Gastroesophageal reflux disease (GERD) The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

A nurse is evaluating education provided to various clients being discharged to home. The nurse assesses that client most likely to be nonadherent with treatment is the one who A) Has tuberculosis and is taking multiple antitubercular medications B) Has pneumonia and is prescribed an oral antibiotic C) Had abdominal surgery and will be changing the dressing daily D) Has a duodenal ulcer and is prescribed a histamine-2 receptor blocker

A) Has tuberculosis and is taking multiple antitubercular medications Client adherence is low when the treatment plan is complex or of long duration. The client with tuberculosis will take multiple antitubercular medications for 9 to 10 months. The other clients are experiencing disturbances and treatments of short duration.

What complication is the nurse aware of that is associated with deep venous thrombosis? A) Pulmonary embolism B) Immobility because of calf pain C) Marked tenderness over the anteromedial surface of the thigh D) Swelling of the entire leg owing to edema

A) Pulmonary embolism Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? A) international normalized ratio (INR) B) partial thromboplastic time (PTT) C) complete blood count (CBC) D) Sodium

A) international normalized ratio (INR) The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of warfarin.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be: A) Attributed to a specific cause. B) Prolonged in duration. C) Rapidly occurring and subsiding with treatment. D) Separate from any central or peripheral pathology.

B) Prolonged in duration. A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

What finding by the nurse may indicate that the client has chronic hypoxia? A) Crackles B) Peripheral edema C) Clubbing of the fingers D) Cyanosis

C) Clubbing of the fingers Clubbing of the fingers is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung. The other signs listed may represent only a temporary hypoxia.

A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed? A) Ipratropium bromide B) Fluticasone propionate C) Ipratropium bromide and albuterol sulfate D) Albuterol

D) Albuterol Albuterol (Proventil), a SABA, is given to asthmatic patients for quick relief of symptoms. Ipratropium bromide (Atrovent) is an anticholinergic. Ipratropium bromide and albuterol sulfate (Combivent) is a combination SABA/anticholinergic, and Fluticasone propionate (Flonase) is a corticosteroid.

A client has an abnormal result on a Papanicolaou test. The client asks the nurse what dysplasia means. Which definition should the nurse provide? A) Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin B) Increase in the number of normal cells in a normal arrangement in a tissue or an organ C) Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found D) Alteration in the size, shape, and organization of differentiated cells

D) Alteration in the size, shape, and organization of differentiated cells The nurse should explain that dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? A) Acute respiratory obstruction B) Adult respiratory distress syndrome C) Pneumothorax D) Asthma

D) Asthma The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.

A nurse working as part of a genetics counseling team is preparing a presentation for a career day discussion at a local college of nursing. When describing the genomic framework for nursing, which of the following would the nurse include as being most important? A) Having a thorough understanding of the various technologies available B) Experiencing first-hand providing care for a wide range of genetic conditions C) Obtaining in-depth knowledge about the variety of cultural beliefs related to the causes of illness D) Being keenly aware of one's own attitudes and assumptions about genetics and genomics

D) Being keenly aware of one's own attitudes and assumptions about genetics and genomics An awareness of one's attitudes and assumptions about genetic and genomics and how these are manifested in one's own practice is essential to a genetic and genomic framework in nursing. Experiences with various genetic conditions, knowledge of beliefs or values about health as well as family, religious, and cultural beliefs, and an understanding of the technologies available are elements that are important in developing one's own awareness.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? A) Hypotension, hyperoxemia, and hypercapnia B) Hyperventilation, hypertension, and hypocapnia C) Hyperoxemia, hypocapnia, and hyperventilation D) Hypercapnia, hypoventilation, and hypoxemia

D) Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

A patient has a hemoglobin level of 7 g/dL. What should the nurse be alert to assess for? A) Hyperemia B) Hypertension C) Hypoglycemia D) Hypoxia

D) Hypoxia Inadequate cellular oxygenation (hypoxia) interferes with the cell's ability to transform energy. Hypoxia may be caused by a decrease in blood supply to an area, a decrease in the oxygen- carrying capacity of the blood (decreased hemoglobin), a ventilation-perfusion or respiratory problem that reduces the amount of arterial oxygen available, or a problem in the cell's enzyme system that makes it unable to use oxygen.

When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care? A) Time, distance, and shielding B) The use of disposable utensils and wash cloths C) Avoid showering or washing over skin markings. D) Inspect the skin frequently.

D) Inspect the skin frequently. Inspecting the skin frequently will allow early identification and intervention of skin problems associated with external radiation therapy. The external markings should not be removed, but clients may shower and lightly wash over the skin. Time, distance, and shielding are key in the management of sealed, internal radiation therapy and not external beam radiation. The use of disposable utensils and care items would be important when caring for clients following systemic, unsealed, internal radiation therapy.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: A) metabolic acidosis. B) metabolic alkalosis. C) respiratory acidosis. D) respiratory alkalosis.

D) respiratory alkalosis. This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next A) Administers oxygen by nasal cannula at 2 liters per minute B) Re-assesses the vital signs C) Contacts the admitting physician D) Calls the Rapid Response Team

A) Administers oxygen by nasal cannula at 2 liters per minute The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

A nurse determines that a patient has poor nutrition based on which assessment finding? A) Beefy-red tongue B) Nonpalpable thyroid gland C) Pink conjunctiva D) Firmly developed muscles

A) Beefy-red tongue Signs of poor nutrition include a beefy-red tongue, palpable thyroid gland, pale eye membranes, and flaccid, poorly toned, wasted, or underdeveloped muscles.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. A) Compromised gas exchange B) Decreased airflow C) Wheezes D) Jugular vein distention E) Ascites

A) Compromised gas exchange B) Decreased airflow C) Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate the development of left ventricular failure? A) Dyspnea, orthopnea, pulmonary edema B) Distended jugular veins, pedal edema, nausea C) Dyspnea, distended jugular veins, orthopnea D) Orthopnea, nausea, pedal edema

A) Dyspnea, orthopnea, pulmonary edema Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea, PND, and pulmonary edema. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right sided heart failure.

Which is the first step in establishing a pattern of inheritance? A) Pedigree B) Genotype C) Transcription D) Mutation

A) Pedigree A pedigree is a first step in establishing the pattern of inheritance. A genotype consists of the genes and variations therein that a person inherits from his or her parents. Transcription is the process of transforming information from DNA into new strands of messenger RNA. Mutation is a heritable alteration in genetic material.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. nutritional status A) age B) physical condition C) gender D) health status E) Ethnicity

A) age B) physical condition D) health status E) Ethnicity General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.

The physician has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a client. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis? A) Immunosuppression B) Inflammation C) Infection D) Hemostasis

B) Inflammation High-sensitivity CRP is a protein produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis.

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? A) Medical directive by proxy B) Living will declaration C) Durable power of attorney for health care D) End-of-life treatment directive

C) Durable power of attorney for health care A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

A nurse, working in a health clinic, treats a variety of conditions on a daily basis. One disorder that is rapidly increasing and is the leading cause of secondary morbidity is: A) Kidney disease B) Coronary heart disease C) Obesity D) Pneumonia

C) Obesity Currently about 30 % of adults and 16% of children are classified as obese (CDC, 2009). Obesity is the leading cause of secondary illnesses ranging from cancer to diabetes.

To help prevent the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use which equipment? A) A trochanter roll extending from the crest of the ilium to the midthigh B) Pillows under the lower legs C) A hip-abductor pillow D) A footboard

A) A trochanter roll extending from the crest of the ilium to the midthigh A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Pillows under the legs or a footboard will not prevent the hips from rotating externally. A hip-abductor pillow is used after total hip replacement surgery.

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use? A) Burning B) Chronic C) Intermittent D) Severe

A) Burning When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.) A) Heart rate B) Respiratory rate C) Heart rhythm D) Character of apical and peripheral pulses E) Lung sounds

A) Heart rate C) Heart rhythm D) Character of apical and peripheral pulses During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the apical and peripheral pulses to detect the effects of hypertension on the heart and blood vessels.

The home health nurse is planning teaching for a client with COPD and a history of noncompliance to the medication regimen. Which factor does the nurse recognize as having the most influence on enabling complete adherence to a health regimen? A) Motivation B) Self-esteem C) Cost of medication D) Education level

A) Motivation The most influential factor that enables complete adherence to a health regimen is client motivation. The client's self-esteem, the cost of medication, and the client's level of education may influence a client's motivation, but these are not the most influential.

The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? A) hypovolemia B) vagal stimulation C) hypothyroidism D) digoxin

A) hypovolemia The causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, hypothyroidism, and digoxin will cause a sinus bradycardia.

A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first appropriate response from the nurse is: A) "Nicotine patches would be appropriate for you." B) "Have you tried to quit smoking before?" C) "I can refer you to the American Lung Association." D) "Many options are available for you."

B) "Have you tried to quit smoking before?" All the options are appropriate statements; however, the nurse needs to assess the client's statement further. Assessment data include information about previous attempts to quit smoking.

Brain cell death may occur in as little as: A) 1 minute B) 3 minutes C) 5 minutes D) 7 minutes

B) 3 minutes The length of time that different tissues can survive without oxygen varies. Brain cells may succumb in 3 to 6 minutes, depending on the situation.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D)) Stage IV pressure ulcer

B) Stage II pressure ulcer A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of A) Degeneration in the efficiency of bone joints B) The client's failure to exercise C) Loss of bone density D) Decreased muscle mass and joint cartilage

C) Loss of bone density Elderly clients experience decreased bone density; they also may experience a loss of bone density from insufficient exercise. For this client, however, additional information indicates that she is taking prednisone, which may induce osteoporosis (loss of bone density). No information indicates that the client is not exercising or has experienced degeneration of bone joints. Degeneration in the efficiency of the bone joints and decreased muscle mass and joint cartilage would have more of an effect on increased pain than on decreased height.

A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need for which accomplishments? Select all that apply. A) Alleviate and manage symptoms B) Validate individual self-worth C) Ignore threats to identity D) Return to a better state of health than prior E) Validate family functioning

A) Alleviate and manage symptoms B) Validate individual self-worth E) Validate family functioning The challenges of living with chronic conditions include the need to accomplish the following: alleviate and manage symptoms, validate individual self-worth and family functioning, manage threats to identity, and die with dignity and comfort.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply. A) Bathing B) Cleaning C) Cooking D) Toileting E) Eating

A) Bathing D) Toileting E) Eating ADLs refer to those activities related to personal care, such as bathing, using the toilet, and eating. Cleaning and cooking are independent ADLs--activities that are important for independent living.

Which type of surgery is used in an attempt to relieve complications of cancer? A) Palliative B) Prophylactic C) Reconstructive D) Salvage

A) Palliative Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.

A nurse is preparing a presentation for a local senior center about the health status of older adults. What trends in health promotion and disease prevention activities would the nurse explain as contributing to declining death rates in the older adult population? Select all that apply. A) decreased smoking B) improved nutrition C) screening for hypertension D) early detection of elevated cholesterol levels E) decreased exercise F) decreased community-based services

A) decreased smoking B) improved nutrition C) screening for hypertension D) early detection of elevated cholesterol levels Most deaths in the United States occur in people 65 years or older, with one-half of these caused by heart disease and cancer. Decreased smoking, improved nutrition, screening for hypertension, and early detection of elevated cholesterol levels are contributing factors to a decreased death rate in older adults. Older adults are encouraged to increase exercise and increase community-based services.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as A) emergency. B) urgent. C) required. D) elective.

A) emergency. Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this laboratory finding, the nurse should suspect that the A) malignancy is causing the electrolyte imbalance. B) client's diet is lacking in calcium-rich food products. C) client may be developing hyperaldosteronism. D) client has a history of alcohol abuse.

A) malignancy is causing the electrolyte imbalance. The client's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium concentration >10.2 mg/dL (>2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia through a variety of mechanisms. The client's calcium level is elevated; there is no indication that the client's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? A) "After surgery you will have a sore throat, but you will be able to speak." B) "You can use writing or a communication board to communicate." C) "After surgery you will have to use an electric larynx to communicate." D) "A speech therapist will evaluate you and recommend a system of communication after surgery."

B) "You can use writing or a communication board to communicate." If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk? A) 18 B) 23 C) 28 D) 31

B) 23 Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A) A client receiving oxygen therapy via Venturi mask B) A client experiencing hypothermia C) A client sitting in a chair after prolonged bed rest D) A client on a ventilator with PEEP

B) A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

Which is a potential complication of a low pressure in the endotracheal tube cuff? A) Tracheal bleeding B) Aspiration pneumonia C) Tracheal ischemia D) Pressure necrosis

B) Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

A patient who is Asian practices the yin/yang theory of harmony and illness. What paradigm of health and illness is this practice rooted in? A) Biomedical B) Holistic C) Religious D) Scientific

B) Holistic The naturalistic or holistic perspective is another viewpoint that explains the cause of illness and is commonly embraced by many Native Americans, Asians, and others. According to this view, the forces of nature must be kept in natural balance or harmony. One example of a naturalistic belief, held by many Asian groups, is the yin/yang theory, in which health is believed to exist when all aspects of a person are in perfect balance or harmony. Rooted in the ancient Chinese philosophy of Taoism (which translates as "The Way"), the yin/yang theory proposes that all organisms and objects in the universe consist of yin and yang energy.

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks? A) Myoglobin B) Troponin C) Total creatine kinase D) CK-MB

B) Troponin Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin peaks within 12 hours after the onset of symptoms. Total creatine kinase (CK) returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

A client in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the client will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the client's age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to ≤ 120/75 mm Hg as quickly as possible.

C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a client whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis? A) Cardiac cauterization B) Computed tomography C) Echocardiography D) Chest x-ray

C) Echocardiography Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

A nurse is working with a family that is under stress. Which trait would the nurse emphasize in the plan of care as being most useful to the family's coping? A) Emotional strengths B) Cognitive abilities C) Individual talents D) Communication skills

D) Communication skills Communication skills and spirituality have been identified as the most useful traits that enhance family members' coping. Other helpful traits include cognitive abilities, emotional strengths, individual strengths and talents, relationship capabilities, and willingness to use community resources.

Which of the following actions by the nurse is appropriate? A) Touching the edges of an open sterile package B) Touching sterile items with a clean-gloved hand C) Reaching over the sterile field D) Discarding an object that comes in contact with the 1-inch border

D) Discarding an object that comes in contact with the 1-inch border The 1-inch border of a sterile field is considered unsterile.

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is A) Acute pain related to upper airway irritation B) Deficient fluid volume related to increased fluid needs C) Deficient knowledge related to prevention of upper respiratory infections D) Ineffective airway clearance related to excess mucus production

D) Ineffective airway clearance related to excess mucus production All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? A) Confusion and seizures B) Sunken eyeballs and spasticity C) Flaccidity and thirst D) Tetany and increased blood urea nitrogen (BUN) levels

A) Confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? A) P wave B) PR interval C) QRS complex D) T wave

A) P wave The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.) A) The primary method of payment B) A comprehensive body systems review C) What the patient ate prior to coming to the clinic D) Current and past medical problems E) Family history

B) A comprehensive body systems review D) Current and past medical problems E) Family history The health history is a series of questions used to provide an overview of the patient's current health status. Many nurses are responsible for obtaining a detailed history of the person's current health problems, past medical history and family history, and a review of the person's functional status. This results in a total health profile that focuses on health as well as illness. The format of the health history traditionally combines the medical history and the nursing assessment. Both the review of systems and the patient profile are expanded to include individual and family relationships, lifestyle patterns, health practices and nutritional assessment, and coping strategies.

The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm? A) Atrial fibrillation B) Atrial flutter C) Ventricular tachycardia D) Ventricular fibrillation

B) Atrial flutter Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial rate, usually between 250 and 400 bpm and results in P waves that are saw-toothed. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. This is an important feature of this dysrhythmia. If all atrial impulses were conducted to the ventricle, the ventricular rate would also be 250 to 400 bpm, which would result in ventricular fibrillation, a life-threatening dysrhythmia. Atrial flutter often occurs in patients with chronic obstructive pulmonary disease, pulmonary hypertension, valvular disease, and thyrotoxicosis, as well as following open heart surgery and repair of congenital cardiac defects (Fuster, Walsh et al., 2011).

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? A) No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis C) Can't assess tumor or regional lymph nodes and no evidence of metastasis D) Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? A) Respiratory rate B) Cyanosis C) Son's statement D) Crackles

B) Cyanosis The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? A) The pericardial space is eliminated with scar tissue and thickened pericardium. B) Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. C) The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction. D) Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

B) Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

Of the following nurse theorists, which one is considered the founder of transcultural nursing? A) Dorothea Orem B) Madeline Leininger C) Jean Watson D) Patricia Benner

B) Madeline Leininger Madeleine Leininger is the founder of the specialty called transcultural nursing. Jean Watson founded the caring theory, Orem the self-care theory, and Benner the novice to expert model.

A female client is a carrier for a gene mutation on one of her X chromosomes. Her spouse is unaffected. The nurse understands that which of the following is most likely? A) The client has signs and symptoms of the condition. B) The client's sons have a 50% chance of being affected. C) Any daughters of the client would be carriers for the disorder. D) The risk of transmitting the disorder is negligible.

B) The client's sons have a 50% chance of being affected.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? A) Measuring and recording fluid intake and output B) Weighing the client daily at the same time each day C) Assessing the client's vital signs every 4 hours D) Checking the client's lungs for crackles during every shift

B) Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective? A) skin rash B) peripheral edema C) dry cough D) postural hypotension

B) peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

After teaching nursing students about autosomal-dominant and autosomal-recessive inherited disorders, the instructor determines that the teaching was successful when the class identifies which of the following as true about autosomal-dominant inherited conditions? A) The percentage of people with a trait who manifest it is variable. B) The severity of the manifestations often varies in degrees. C) Males and females are equally affected by this pattern of inheritance. D) Horizontal transmission is more commonly seen in families.

C) Males and females are equally affected by this pattern of inheritance. Autosomal-recessive disorders are transmitted horizontally in families; Autosomal-dominant disorders are transmitted vertically. Autosomal-dominant disorders affect males and females equally and have manifestations that vary in degrees of severity (variable expression). Additionally, the percentage of people known to have the particular genetic mutation who actually show the trait (penetrance) varies.

A nurse is preparing a presentation for a local community group addressing the influences on health care delivery. Which of the following would the nurse include in presentation when describing disease patterns? A) Most infectious diseases have been controlled or eradicated. B) The prevalence of chronic illness is decreasing due to the emphasis on healthy living. C) Obesity along with conditions associated with it has become a major health concern. D) People with acute illnesses are considered the largest group of health care consumers.

C) Obesity along with conditions associated with it has become a major health concern. In recent years, obesity has become a major health concern and the multiple comorbidities that accompany it add significantly to its associated mortality. Although many infectious diseases have been controlled or eradicated, some such as tuberculosis, acquired immunodeficiency syndrome and sexually transmitted infections are on the rise. The prevalence of chronic illnesses and disability is increasing because of the lengthened lifespan in the United States and the advances in care and treatment. People with chronic illnesses constitute the largest group of health care consumers in the United States.

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A) pleural effusion. B) pulmonary edema. C) atelectasis. D) oxygen toxicity.

C) atelectasis. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: A) Blood pressure. B) Breath sounds. C) Renal output. D) Heart rate.

A) Blood pressure. By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? A) Constant, intense back pain and falling blood pressure B) Constant, intense headache and falling blood pressure C) Higher than normal blood pressure and falling hematocrit D) Slow heart rate and high blood pressure

A) Constant, intense back pain and falling blood pressure Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? A) Fibrotic changes in lungs B) Hemorrhage C) Lung contusion D) Damage to surrounding tissues

A) Fibrotic changes in lungs For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client? A) Respect the client's and family members' choices B) Share emotional pain C) Abide by the dying client's wishes D) Ask the family members about spiritual care

A) Respect the client's and family members' choices In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complication(s)? A) Thrombosis and infection B) Bleeding and wound dehiscence C) Bleeding and infection D) Evisceration

C) Bleeding and infection Possible complications of an aortic balloon valvuloplasty include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, infection, and bleeding from the catheter insertion sites.

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? A) Extravasation B) Stomatitis C) Nausea and vomiting D) Bone pain

A) Extravasation The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis, nausea/vomiting, and bone pain can be symptoms of the disease process or treatment mode but does not require immediate action.

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess? A) Lung sounds B) Skin color C) Heart rate D) Respiratory rate

A) Lung sounds A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased? A) Stress incontinence B) Urge incontinence C) Reflex (neurogenic) incontinence D) Functional incontinence

A) Stress incontinence Stress incontinence may occur with coughing or sneezing, which increase intra-abdominal pressure. Urge incontinence is involuntary elimination of urine associated with a strong perceived need to void. Neurogenic incontinence is associated with a spinal cord lesion. Functional incontinence refers to incontinence in clients with intact urinary physiology and who experience mobility impairment, environmental barriers, or cognitive problems.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? A) The client can be discharged from the PACU. B) The client must remain in the PACU. C) The client should be transferred to an intensive care area. D) The client must be put on immediate life support.

A) The client can be discharged from the PACU. The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

B) Ineffective tissue perfusion Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? A) The physician B) The patient C) The physical therapist D) The nurse

B) The patient The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process.

The scrub nurse is responsible for: A) Calling the "time-out" to verify the surgical site and procedure B) Monitoring the administration of the anesthesia C) Monitoring the operating-room personnel for breaks in sterile technique D) Preparing the sterile instruments for the surgical procedure

D) Preparing the sterile instruments for the surgical procedure The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. A) To provide adequate transport of oxygen in the blood B) To decrease the work of breathing C) To reduce stress on the myocardium D) To clear respiratory secretions E) To provide visual feedback to encourage the client to inhale slowly and deeply

A) To provide adequate transport of oxygen in the blood B) To decrease the work of breathing C) To reduce stress on the myocardium Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.

The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure? A) furosemide B) spironolactone C) mannitol D) metolazone

A) furosemide Loop diuretics such as furosemide, bumetanide, and torsemide are the preferred first-line diuretics because of their efficacy in patients with and without renal impairment. Spironolactone is a potassium diuretic. Mannitol is an osmotic diuretic not used for heart failure. Metolazone is a potassium diuretic not used for first treatment for heart failure. Diuretics should never be used alone to treat HF because they don't prevent further myocardial damage.

A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs? A) using a systematic method to plan and implement care to reach desired outcomes B) contacting the physician before performing any tasks C) consulting with other nurses to determine the first step of care D) reading the client's records and doing research on the client's conditions before deciding on a course of action

A) using a systematic method to plan and implement care to reach desired outcomes Clients present with multiple healthcare needs that the caregiver must approach in an organized, systematic manner to provide efficient and effective care. The nursing process for making clinical decisions grew from problem-solving techniques and the scientific process.

Which phase in the trajectory model of chronic illness is characterized by the reactivation of an illness in remission? A) Pretrajectory B) Stable C) Unstable D) Crisis

C) Unstable The unstable phase is characterized by an exacerbation of illness symptoms, development of complications, or reactivation of an illness in remission. The pretrajectory phase is described as the genetic factors or lifestyle behaviors that place a person or community at risk for a chronic condition. In the stable phase the course and symptoms of illness are under control, as symptoms, resulting disability, and everyday life activities are being managed within the limitations of the illness. The crisis phase is a critical or life-threatening situation requiring emergency treatment or care and suspension of everyday life activities until the crisis has passed.

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. A) "How long have you experienced this pain?" B) "Please point to where you are experiencing pain." C) "You've never had this pain before, have you?" D) "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." E) "What aggravates your chest pain?"

A) "How long have you experienced this pain?" B) "Please point to where you are experiencing pain." D) "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." E) "What aggravates your chest pain?" The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective? A) "I will support my incision with my hands when I cough and do my deep breathing exercises." B) "I will ask for pain medication when the pain becomes unbearable." C) "I will need to learn how to give myself pain medication by injection for when I go home." D) "The pain from my incision will be very similar to my arthritis pain."

A) "I will support my incision with my hands when I cough and do my deep breathing exercises." Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.

The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia? A) "The hair loss is usually temporary." B) "New hair growth will return without any change to color or texture." C) "Clients with alopecia will have delay in grey hair." D) "Wigs can be used after the chemotherapy is completed."

A) "The hair loss is usually temporary." Alopecia associated with chemotherapy is usually temporary and will return after the therapy is completed. New hair growth may return unchanged, but there is no guarantee and color, texture, and quality of hair may be changed. There is no correlation between chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings can be used by clients at any time during treatment plan.

A nurse is teaching a client about valve replacement surgery. Which statement by the client indicates an understanding of the benefit of an autograft replacement valve? A) "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." B) "The valve is made from a pig tissue, and I will not need to take any blood-thinning drugs when I am discharged." C) "The valve is from a tissue donor, and I will not need to take any blood-thinning drugs when I am discharged." D) "The valve is mechanical, and it will not deteriorate or need replacing."

A) "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." Autografts (i.e., autologous valves) are obtained by excising the client's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the client's own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, clients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? A) Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax B) Asking the client to say "one, two, three" while the nurse auscultates the lungs C) Instructing the client to take a deep breath and hold it while the diaphragm is percussed D) Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

A) Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. A) Assess the client who is at risk for shock. B) Administer vasoconstrictive medications to clients at risk for shock. C) Administer prophylactic packed red blood cells to clients at risk for shock. D) Administer intravenous fluids. E) Monitor for changes in vital signs.

A) Assess the client who is at risk for shock. D) Administer intravenous fluids. E) Monitor for changes in vital signs. Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

For a client with an endotracheal (ET) tube, which nursing action is the most important? A) Auscultating the lungs for bilateral breath sounds B) Turning the client from side to side every 2 hours C) Monitoring serial blood gas values every 4 hours D) Providing frequent oral hygiene

A) Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

The nurse is teaching about preventing pneumonia and influenza to a group of clients in a senior citizens' wellness class. The nurse includes which of the following topics in the class? Select all options that apply. A) Avoiding environmental smoke B) Participating in regular exercise C) Ensuring appropriate fluid intake D) Avoiding all sun exposure E) Following a high-calcium diet

A) Avoiding environmental smoke B) Participating in regular exercise C) Ensuring appropriate fluid intake Activities that help elderly clients maintain good respiratory function include avoiding environmental smoke, regularly exercising, and ensuring appropriate fluid intake. Sun exposure and a high-calcium diet are health-promotion strategies for the integumentary and musculoskeletal systems respectively.

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? A) Chest discomfort not relieved by rest or nitroglycerin B) Intermittent nausea and emesis for 3 days C) Cool, clammy skin and a diaphoretic, pale appearance D) Anxiousness, restlessness, and lightheadedness

A) Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

The nurse listens to a client explain that she is receiving manipulations from a health care provider. The nurse documents in the client's chart that the client is using which therapy? A) Chiropractic B) Therapeutic touch C) Reiki D) Herbal

A) Chiropractic Chiropractic therapy involves manipulation as an intervention on body movement. Both Reiki and therapeutic touch are forms of energy therapy whereby the practitioner focuses on the energy fields within or outside of the body. Herbal therapy involves using a plant or plant parts to act on the body.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: A) Cigarette smoking. B) Lack of exercise. C) Obesity. D) Stress.

A) Cigarette smoking. Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? A) Confusion B) Headache C) Nausea D) Hallucinations

A) Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? A) Crackles in the lung bases B) Low-pitched rhonchi during expiration C) Pleural friction rub D) Sibilant wheezes

A) Crackles in the lung bases When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.

The nurse observes that a coworker is unable to understand that an intelligent person would engage the services of a medicine man. The nurse's coworker has strong ethnocentric tendencies and an inability to recognize others' values, beliefs, and practices. The nurse understands that the coworker's behavior is an example of which attitude? A) Cultural blindness B) Cultural taboo C) Cultural imposition D) Acculturation

A) Cultural blindness Cultural blindness results in bias and stereotyping. Cultural taboos are those activities governed by rules of behavior that are avoided, forbidden, or prohibited by a particular cultural group. Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Acculturation is the process by which members of a culture adapt or learn how to take on the behaviors of another group.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? A) Dantrolene sodium B) Fentanyl citrate C) Naloxone D) Thiopental sodium

A) Dantrolene sodium Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? A) Decreased acetylcholine level B) Increased acetylcholine level C) Increased norepinephrine level D) Decreased norepinephrine level

A) Decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

Which is a characteristic of arterial insufficiency? A) Diminished or absent pulses B) Superficial ulcer C) Aching, cramping pain D) Pulses are present but may be difficult to palpate

A) Diminished or absent pulses A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? A) During the preoperative period B) Upon arrival to the surgical unit C) Following the surgical procedure D) At the time of discharge instructions

A) During the preoperative period The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time.

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations? A) Encourage the family members to express their feelings and listen to them in their frank communication. B) Encourage conversations on the impending death of the patient. C) Be a silent observer and allow the patient to communicate with the family members. D) Encourage the patient's family members to spend time with the patient.

A) Encourage the family members to express their feelings and listen to them in their frank communication. Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying patient. It is not advisable for the nurse to encourage conversations on the impending death of the patient. Being a silent observer or encouraging the family members to spend time with the dying patient may not help the family members to express their feelings.

Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage? A) Hypertensive emergency B) Hypertensive urgency C) Primary hypertension D) Secondary hypertension

A) Hypertensive emergency A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure from an unidentified source.

Which is a cause related to the increasing number of people with chronic conditions? A) Improved screening and diagnostic procedures B) An increase in mortality from infectious disease C) A tendency for these conditions to develop in younger people D) Shorter lifespans

A) Improved screening and diagnostic procedures The increasing number of people with chronic conditions is related to improved screening and diagnostic procedures. Mortality from infectious disease has been decreasing. Chronic conditions tend to develop in the elderly population. People are living longer for various reasons.

Which capability corresponds with home health care? A) Improvises when providing care B) Retains maximal control over the client's lifestyle C) Is unable to care for those living in substandard conditions D) Uses a wide variety of supplies and equipment

A) Improvises when providing care The nurse has to learn to improvise when providing care. The home health nurse is considered a guest in the patient's home and must have permission to visit and give care. The cleanliness of the patient's home may not meet the standards of a hospital. The kind of equipment and the supplies or resources that are usually available in acute care settings are often unavailable in the patient's home.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs? A) Initiate enteral feedings. B) Offer plenty of thin liquids. C) Encourage sweet foods. D) Liberally season foods.

A) Initiate enteral feedings. Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.

The nurse educator is planning a teaching session for nursing students related to the treatment and management of gestational diabetes. The nurse educator arranges for a dietitian, pharmacist, and physician assistant to participate in the lesson plan. Which professional nurse competency is the nurse educator demonstrating? A) Interdisciplinary teamwork B) Patient-centered care C) Evidence-based practice D) Quality improvement measures

A) Interdisciplinary teamwork By integrating interdisciplinary core competencies into the curriculum, the nurse educator is demonstrating interdisciplinary teamwork. A case-study approach planning care around individual patient preferences is an example of patient-centered care. Conducting a review of the evidence-based literature related to gestational diabetes reflects evidence-based practice. Providing education related to measures/indicators or tools used to assess the level of care provided within a system of care to populations of patients with gestational diabetes exemplifies a quality improvement measure.

Which of the following is an example of adherence to treatment? Select all that apply. A) Maintaining a healthy diet B) Self-monitoring for signs and symptoms of illness C) Taking prescribed medications D) Increasing daily activities E) Inability to comply with follow-up appointments

A) Maintaining a healthy diet B) Self-monitoring for signs and symptoms of illness C) Taking prescribed medications D) Increasing daily activities Examples of behaviors facilitating health include taking prescribed medications, maintaining a healthy diet, increasing daily activities and exercise, self-monitoring for signs and symptoms of illness, practicing specific hygiene measures, seeking recommended health evaluations and screening, and performing other therapeutic and preventative measures. Inability to comply with follow-up appointments is not an example of adherence to treatment.

Based on the nurse's knowledge of the increased risk for bleeding in a client undergoing chemotherapy or radiation, which of the following interventions does the nurse need to include in the client's plan of care? Select all that apply. A) Monitoring the platelet count B) Monitoring for signs of abnormal bleeding C) Instructing the client to use a soft toothbrush D) Instructing the client to use an electric razor E) Instructing the client to add low-dose aspirin to daily medication regimen F) Increasing the patient's injections for pain control

A) Monitoring the platelet count B) Monitoring for signs of abnormal bleeding C) Instructing the client to use a soft toothbrush D) Instructing the client to use an electric razor Utilizing critical thinking skills, the nurse knows to implement individualized interventions to reduce the client's risk of bleeding. Hence, the nurse must frequently assess platelet counts, monitor for signs of abnormal bleeding, and instruct the client and family about ways to minimize bleeding, such as using a soft toothbrush and/or an electric razor. Medications that may interfere with clotting, such as aspirin, should be avoided, and blood draws and injections should be kept to a minimum.

Which statement provides accurate information related to chronic illness? A) Most people with chronic conditions take on a sick role identity. B) Chronic conditions do not result from injury. C) Most people with chronic conditions do not consider themselves sick or ill. D) Most chronic conditions are easily controlled.

A) Most people with chronic conditions take on a sick role identity Most people with chronic conditions do not consider themselves sick or ill and try to live as normal a life as is possible. Although research has demonstrated that some people take on a "sick role" identity, they are not the majority. Chronic conditions may be due to illness, genetic factors, or injury. Many chronic conditions require therapeutic regimens to keep them under control.

A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 mg/dL (1.9 mmol/L). Which physical examination finding is consistent with this electrolyte imbalance? A) Presence of Trousseau sign B) Slurred speech C) Negative Chvostek sign D) Muscle weakness

A) Presence of Trousseau sign After radical neck resection, a client is prone to developing hypocalcemia. Hypocalcemia is defined as a serum value <8.6 mg/dL (<2.15 mmol/L). Signs and symptoms of hypocalcemia include Chvostek sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped; and a positive Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.

A client in an acute care facility is assigned a case manager to oversee and coordinate care. What important function does a case manager have? A) Provide early, thorough discharge planning. B) Make sure the client is administered medications. C) Provide care to the client who is terminally ill and has less than 6 months to live. D) Make home visits to see that the client is taken care of after discharge.

A) Provide early, thorough discharge planning. An important function of case managers is to provide early, thorough discharge planning. The case manager is not responsible for the administration of medications. Hospice care provides care to the client who is terminally ill. The case manager oversees the care of the clients while they are hospitalized. Referrals to community agencies and home healthcare will be made for home visits.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? A) Rapid onset of severe dyspnea B) Inspiratory crackles C) Bilateral wheezing D) Cyanosis

A) Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

Which clinical manifestation is often the earliest sign of malignant hyperthermia? A) Tachycardia (heart rate >150 beats per minute) B) Hypotension C) Elevated temperature D) Oliguria

A) Tachycardia (heart rate >150 beats per minute) Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.

In which situation is the nurse providing tertiary prevention? A) Teaching rehabilitation exercises to a client after a mastectomy B) Educating teens on the importance of sunscreen to reduce the risk of skin cancer C) Providing breast cancer screening information to a high-risk population D) Evaluating client understanding of discharge instructions

A) Teaching rehabilitation exercises to a client after a mastectomy Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. The focus on primary prevention is on health promotion and prevention of illness or disease. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence. Evaluating patient understanding of discharge instructions is important, but it does not focus on health promotion and prevention of illness or disease.

The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm below. What dysthymia should the nurse document? A) ventricular tachycardia B) ventricular asystole C) sinus rhythm D) junctional rhythm

A) ventricular tachycardia The dysrhythmia is ventricular tachycardia because it has more than 3 premature ventricular contractions. Ventricular Asystole is characterized by absent QRS complexes. This rhythm is referred as flatline. Sinus rhythm will have a ventricular and atrial rate of 60 to 100 bpm. The ventricular and atrial rhythm will be regular. The QRS shape and duration is normal, but may be regularly abnormal. The P-wave will be normal and consistent shape and is always in front of the QRS. The PR interval is a consistent interval between 0.12 and 0.20 seconds. The P:QRS ratio is 1:1. Junctional rhythm will have a ventricular rate of 40 to 60 bpm and an atrial rate of 40 to 60 bpm. The ventricular and atrial rhythm will be regular. The QRS shape and duration is normal, but may be abnormal. The P-wave may be absent after the QRS complex, or before the QRS. The PR interval, if the P-wave is in front of the QRS, the PR interval is less than 0.12 seconds. The P:QRS ratio is 1:1 or 0:1. Atrial fibrillation will have a ventricular and atrial rate of 300 to 600 bpm. The ventricular rate is usually 120 to 200 bpm if untreated. The ventricular and atrial rhythm is highly irregular. The QRS shape and duration is usually normal, but may be abnormal. The P-waves will not be discernible, and will be irregular. The PR interval cannot be measured. The P:QRS ratio is Many:1

After teaching nursing students about the health-illness continuum, the instructor determines that teaching was successful when the students state which of the following? A) "A patient's care must be focused on treating the disease." B) "A person can be both healthy and ill at the same time." C) "A patient with a disease typically falls on the far end of the continuum." D) "A patient with a chronic illness is considered ill."

B) "A person can be both healthy and ill at the same time." By viewing health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor completely ill. Instead, a person's state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death. Use of the health-illness continuum makes it possible to regard a person as simultaneously possessing degrees of both health and illness. Patient care should not focus just on the treatment of disease; people do have varying degrees of illness, and care should focus on the patient's response to all aspects of nursing care. A patient with a chronic illness or disability may attain a high level of wellness if he or she is successful in meeting health needs within the limits of his or her illness or disability.

The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. This pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud disease

B) Intermittent claudication A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of these health problems produce this cluster of signs and symptoms.

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? A) venous pressure of 6 mm Hg B) Mean arterial pressure of 70 mm Hg C) Urine output of 0.2 mL/kg/hr D) ScvO2 of 60%

B) Mean arterial pressure of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? A) Inpatient respite care B) Palliative care C) Continuous care D) General inpatient care

B) Palliative care Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response? A) Return the client to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the client's blood pressure and pulse. D) Pull the dehiscence closed using gloved hands.

B) Place saline-soaked sterile dressings on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply. A) Gallbladder disease B) Smoking C) Diabetes mellitus D) Physical inactivity E) Frequent upper respiratory infections

B) Smoking C) Diabetes mellitus D) Physical inactivity Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history.

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? A) To dilate coronary arteries B) To decrease workload of the heart C) To decrease homocysteine levels D) To prevent angiotensin II conversion

B) To decrease workload of the heart Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? A) corticosteroids B) diuretics C) insulin D) anticoagulants

B) diuretics Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids, insulin, and anticoagulants are not known to cause respiratory depression during anesthesia.

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? A) liver dysfunction B) organ damage C) weight loss D) unsteady gait

B) organ damage When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A) Abdominal tightness B) Abdominal distention C) Absence of peristalsis D) Increased abdominal girth

C) Absence of peristalsis Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.

Which is the best thing the nurse can do to provide culturally sensitive care? A) Become familiar with physical differences among ethnic groups. B) Provide the proper food for nourishment. C) Accept each client as a unique individual. D) Facilitate rituals that bring comfort to the client.

C) Accept each client as a unique individual. Becoming familiar with physical differences, providing food that is customary to the culture, and facilitating rituals are all recommendations for enhancing sensitive cultural care, but according to Leininger, accepting each client as an individual is a characteristic that is found in the specialty of transcultural nursing.

The use of patient restraints limits which ethical principle? A) Beneficence B) Justice C) Autonomy D) Trust

C) Autonomy It is important to weigh carefully the risk of limiting a client's autonomy and increasing the risk of injury by using restraints against the risk of not using restraints. Beneficence refers to an act of goodness, justice in nursing often refers to bioethics and means giving to others what is due, finally trust is building a relationship based on reliability and truths. The patient's autonomy is limited with the use of restraints.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? A) Observe for mist in the endotracheal tube. B) Listen for breath sounds over the epigastrium. C) Call for a chest x-ray. D) Attach a pulse oximeter probe and obtain values.

C) Call for a chest x-ray. A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the mosteffective for this client? A) Surgery to remove the tonsils and adenoids B) Medications to assist the patient with sleep at night C) Continuous positive airway pressure (CPAP) D) Bi-level positive airway pressure (BiPAP)

C) Continuous positive airway pressure (CPAP) CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels? A) RBC B) Platelets C) Enzymes D) WBC

C) Enzymes When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.

When providing care to a patient with anxiety, which intervention would be the highest priority? A) Improving the patient's sleeping patterns B) Ensuring adequate nutritional intake C) Exploring appropriate coping strategies D) Administering prescribed anti-anxiety medications

C) Exploring appropriate coping strategies For the patient with anxiety, the priorities of care include teaching and promoting effective coping abilities and use of relaxation techniques. Improving sleeping patterns, ensuring adequate nutrition, and administering prescribed medications would also be important, but these would not be considered most important.

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? A) Epistaxis, twice last week B) Aphonia following a football game C) Hoarseness for 2 weeks D) Laryngitis following a cold

C) Hoarseness for 2 weeks Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.

There are many goals for health teaching. Which of the following is the primary goal of family and patient education? A) Increase knowledge B) Motivate people to learn C) Improve patient outcomes D) Establish trust

C) Improve patient outcomes The primary goal of patient and family education is to achieve, improve, or alter behaviors that directly or indirectly change and improve patient outcomes.

Which valve lies between the right ventricle and the pulmonary artery? A) Tricuspid valve B) Mitral valve C) Pulmonic valve D) Chordae tendineae

C) Pulmonic valve The pulmonic valve is a semilunar valve located between the right ventricle and the pulmonary artery. The tricuspid valve is an atrioventricular valve located between the right atrium and right ventricle. The mitral valve is an atrioventricular valve located between the left atrium and left ventricle. Chordae tendineae anchor the valve leaflets to the papillary muscle and ventricular wall.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A) The system is functioning normally. B) The client has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.

C) The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? A) Intractable B) Variant C) Unstable D) Refractory

C) Unstable Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? A) "What concerns you most about Alzheimer disease?" B) "Alzheimer disease can be a great burden on the family. What community resources do you know about?" C) "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." D) "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."

D) "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." Delirium is associated with a sudden onset of confusion, not Alzheimer disease. The family needs to be told the correct information, which is that several underlying conditions could be causing the confusion. Once the underlying cause(s) is found and treated, the confusion should subside; however, some clients may not recover from the underlying cause, so telling the family the client will be better than ever is not appropriate. Asking the family about their concerns about Alzheimer disease and what they know about community support related to it is not appropriate because the client is exhibiting symptoms related to delirium.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect? A) Placebo B) Dependence C) Tolerance D) Addiction

D) Addiction Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.+

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? A) Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. B) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider. C) Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. D) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

D) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

A community health nurse understands the importance and impact of cultural competence when caring for clients in the community. In what situation will the nurse find that cultural competence is particularly important? A) When members of the community request religious resources B) When the nurse works in a larger city versus a small community C) When the nurse is new to the job and the role within the community D) When members of the community share a heritage that is unfamiliar to the nurse

D) When members of the community share a heritage that is unfamiliar to the nurse When members of the community share a heritage that is unfamiliar to the nurse, the nurse must be very aware of the importance of cultural competence. Although the other answer choices may present challenges to the nurse, these are not universally true and are therefore not the best answer choices.

The nurse is assessing a patient's blood pressure. What does the nurse document as the difference between the systolic and the diastolic pressure? A) Pulse pressure B) Auscultatory gap C) Pulse deficit D) Korotkoff sound

A) Pulse pressure The difference between the systolic and the diastolic pressures is called the pulse pressure.

A 66-year-old client presents to the emergency department reporting severe headache and mild nausea for the past 6 hours. Upon assessment, the client's BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0 mg clonidine twice daily. Which question is most important for the nurse to ask the client next? A) "Have you taken your prescribed clonidine today?" B) "Do you have a dry mouth or nasal congestion?" C) "Are you having chest pain or shortness of breath?" D) "Did you take any medication for your headache?"

A) "Have you taken your prescribed clonidine today?" The nurse must ask whether the client has taken his prescribed clonidine. Clients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of clonidine is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire whether the client has taken the prescribed hypertension medication given the client's severely elevated BP.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? A) Circulating nurse B) Scrub nurse C) Surgeon D) Registered nurse first assistant

A) Circulating nurse The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.

Which term is defined as a formal systematic study of moral beliefs? A) Ethics B) Veracity C) Fidelity D) Morality

A) Ethics Ethics is the formal, systematic study of moral beliefs. Veracity is the obligation to tell the truth and not to lie or deceive others. Fidelity is keeping promises. Morality is the adherence to informal personal values.

As the moment of death approaches, which of the following does the nurse encourage the family to do? A) Have the family sit in front of the client so they can be seen. B) Rub the client's hand and arm to comfort the client. C) Speak to the client in a calm and soothing voice. D) Lie next to the client and hold the client.

C) Speak to the client in a calm and soothing voice. Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

What does decreased pulse pressure reflect? A) tachycardia B) reduced distensibility of the arteries C) reduced stroke volume D) elevated stroke volume

C) reduced stroke volume Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

A waist circumference greater than which value indicates excess abdominal fat in men? A) 63.50 cm (25 in) B) 76.20 cm (30 in) C) 88.90 cm (35 in) D) 101.60 cm (40 in)

D) 101.60 cm (40 in) A waist circumference >101.60 cm (>40 in) for men or >88.90 cm (>35 in) for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.

Which statement is a misconception about chronic disease? A) Almost half of chronic deaths occur prematurely in people B) Chronic illness typically does not result in sudden death. C) The major cause of chronic disease is known. D) Chronic illnesses cannot be prevented.

D) Chronic illnesses cannot be prevented. A misconception regarding chronic disease is that chronic illnesses cannot be prevented. Almost half of chronic illness-related deaths occur prematurely in people younger than 70 years of age. Chronic illness typically does not result in sudden death. The major cause of chronic disease is known.

The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication? A) Variable heart rate, usually fewer than 90 bpm B) Irregular rhythm C) Delayed conduction, producing a prolonged PR interval D) P waves hidden within the QRS complex

C) Delayed conduction, producing a prolonged PR interval First-degree AV block may occur without an underlying pathophysiology, or it can result from medications or conditions that increase parasympathetic tone. It occurs when atrial conduction is delayed through the AV node, resulting in a prolonged PR interval.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully? A) people metabolize drugs more rapidly. B) Older people have increased hepatic, renal, and gastrointestinal function. C) Older people are more sensitive to drugs. D) Older people have lower ratios of body fat and muscle mass.

C) Older people are more sensitive to drugs. Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? A) 3 to 5 days B) 1 to 3 weeks C) 2 to 4 months D) 6 to 12 months

D) 6 to 12 months Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.