MS Evolve

6. The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed."

C. "I may still be able to get pregnant." Many women with spinal cord injury go on to get pregnant and give birth to healthy children. Spinal cord injury is not a disorder that can be inherited.

A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session? A. "Your diseased kidneys will be removed at the same time the transplant is performed." B. "The new kidney will be placed directly below one of your old kidneys." C. "It is essential for you to wash your hands and avoid people who are ill." D. "You will receive dialysis the day before surgery and for about a week after."

C. "It is essential for you to wash your hands and avoid people who are ill." Anti-rejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.

15. Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A. Bathe in cold water. B. Wear cotton gloves when cooking. C. Consume a diet high in fiber. D. Make sure shoes are snug.

C. Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

18. The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Exelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. Memantine (Namenda) is indicated for advanced Alzheimer's disease. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors are antidepressants and may be used in Alzheimer's clients who develop depression. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.

16. The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a check-up?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."

A. "Have you taken her for a check-up?" The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a health care provider. The nurse cannot diagnose Alzheimer's disease. The mother's behavior is not normal age-related behavior. Respite care is for caregivers, not for clients.

7. A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? A. "I can go home the day of the procedure." B. "I can go home 48 hours after the procedure." C. "I'll have a drain in place after the procedure." D. "I'll need to wear special stockings after the procedure."

A. "I can go home the day of the procedure." The client who undergoes a microdiskectomy typically can return home the same day. The client who undergoes a traditional open laminectomy typically can return home 48 hours after the procedure, will have a drain in place after the procedure, and will need to wear special stockings after the procedure.

21. A client has been diagnosed with Huntington disease (HD). The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching? A. "If she has children, she'll pass the gene on to her kids." B. "She could only have gotten the disease from both of us." C. "Because she got the gene from her father, she'll live longer than others with HD." D. "More testing should definitely be done to see if she's really got the gene."

A. "If she has children, she'll pass the gene on to her kids." An autosomal dominant trait with high penetrance, such as HD, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. Only one defective gene is needed to inherit HD. The client could have inherited it from her father or mother. If the client inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. Additional testing is not necessary. If the client has HD, then the client has the gene

14. A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? A. "It should help return bladder control." B. "Let me call the surgeon so you can ask the rest of your questions." C. "What do you think?" D. "What does your family think?"

A. "It should help return bladder control." Surgical decompression may be performed to maintain bladder, bowel, or motor function and to preserve quality of life, even with a poor prognosis. The nurse should ascertain what was explained in the informed consent and then should clarify the information already given by the health care provider. The client must make the decision for surgery, but the nurse should provide additional information to the client, especially if the client asks. The family should not make the decision for surgery, the client should.

12. The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic

A. Absence Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. Partial seizures are most often seen in adults. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

Questions 1. A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Speak loudly for better understanding. D. Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

A. Administer medications promptly on schedule to maintain therapeutic drug levels. Administering medications promptly on schedule is a correct statement. The client should be encouraged to do as much as possible on his own. Slow speech rather than loud speech, and small, frequent meals are more effective for the client with Parkinson disease

4. A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? A. Advance directives B. How to use the ventilator C. Funeral plans D. Nutritional support

A. Advance directives Mechanical ventilation enables the client to breathe and prolongs survival, but it will not alter progression of the disease. For this reason, many clients elect not to be placed on a mechanical ventilator, according to their wishes or advance directives. Ventilator operation and nutrition are not the priority issues to review with this client. Reviewing funeral plans with the client is inappropriate and is not the responsibility of the nurse.

4. A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.

A. Allow the client to remain undisturbed. At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. Assessing the client's vital signs will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

20. The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care

A. Arranges for respite care Respite care can give the wife some time to re-energize and will provide a social outlet for the client. Providing positive reinforcement and support is encouraging, but does not help the wife's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse? _________

167 drops/min 20 gtt × 500 mL = 10,000/60 min = 167 drops/min

Which finding in the first 24 hours after kidney transplantation requires immediate intervention? A. Abrupt decrease in urine output B. Blood-tinged urine C. Incisional pain D. Increase in urine output

A. Abrupt decrease in urine output An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation.

A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Auscultate for pericardial friction rub. B. Assess for crackles. C. Monitor for decreased peripheral pulses. D. Determine if the client is able to ambulate.

A. Auscultate for pericardial friction rub. The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST-segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present. Although the nurse will monitor pulses, and ambulation is important to prevent weakness and deep vein thrombosis, these are not pertinent to the constellation of symptoms of pericarditis that the client presents with.

5. Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a daily vitamin. D. Take prophylactic antibiotics.

B. Get the meningococcal vaccine. Individuals ages 16 to 21 years have the highest rates of meningococcal infection and should be immunized against the virus. Adults are advised to get an initial or booster vaccine if living in a shared residence (residence hall, military barracks, group home), traveling or residing in countries in which the disease is common, or immunocompromised due to a damaged or surgically removed spleen or a serum complement deficiency. Avoiding large crowds is helpful, but is not practical for a college student. Taking a daily vitamin is helpful, but is not the best way to safeguard against bacterial meningitis. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

4. The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A. Veins of the legs B. Lung C. Heart D. Abdominal cavity

D. Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.

18. The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.

The RN has just received change-of-shift report. Which of the assigned clients should be assessed first? A. Client with chronic kidney failure who was just admitted with shortness of breath B. Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted C. Client with azotemia whose blood urea nitrogen and creatinine are increasing D. Client receiving peritoneal dialysis who needs help changing the dialysate bag

A. Client with chronic kidney failure who was just admitted with shortness of breath The dyspnea of the client with chronic kidney failure may indicate pulmonary edema and should be assessed immediately. The client with kidney insufficiency is stable and assessment can be performed later. The client with azotemia requires assessment and possible interventions, but is not at immediate risk for life-threatening problems. The client receiving peritoneal dialysis can be seen last because it is a slow process and the client has no urgent needs.

25. Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A. Cloudy, turbid CSF Cloudy, turbid CSF is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

To prevent pre-renal acute kidney injury, which person is encouraged to increase fluid consumption? A. Construction worker B. Office secretary C. Schoolteacher D. Taxicab driver

A. Construction worker Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and pre-renal azotemia. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker.

16. A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? A. Drowsiness B. Hirsutism C. Hypertension D. Tachycardia

A. Drowsiness Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant, and drowsiness and sedation are common adverse effects. Tizanidine may cause alopecia (not hirsutism), hypotension (not hypertension), and bradycardia (not tachycardia).

When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? A. Eggs B. Ham C. Eggplant D. Macaroni

A. Eggs Suggested protein-containing foods for a client on peritoneal dialysis are milk, meat, and eggs. Although a protein, ham is high in sodium, which should be avoided. Vegetables and pasta contain mostly carbohydrates. Peritoneal dialysis clients are allowed 1.2 to 1.5 g of protein/kg/day because protein is lost with each exchange.

21. Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) A. Fatigue B. Changes in color of hair C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing

A. Fatigue C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.

Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) A. Football player in preseason practice B. Client who underwent contrast dye radiology C. Accident victim recovering from a severe hemorrhage D. Accountant with diabetes E. Client in the intensive care unit on high doses of antibiotics F Client recovering from gastrointestinal influenza

A. Football player in preseason practice B. Client who underwent contrast dye radiology C. Accident victim recovering from a severe hemorrhage E. Client in the intensive care unit on high doses of antibiotics F Client recovering from gastrointestinal influenza To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 liters of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness that reduces kidney blood flow, such as influenza. Contrast media may cause acute renal failure, especially in older clients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure.

5. The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A. Hemoglobin of 7.4 and hematocrit of 21.8 B. Potassium level of 2.9 mEq/L and diarrhea C. 250,000 platelets/mm3 D. 5000 white blood cells/mm3

A. Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.

When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? (Select all that apply.) Physical Assessment Findings Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremors Diagnostic Findings Na: 115 K: 4.2 Creatinine: 0.8 Medications ondansetron (Zofran) cyclophosphamide (Cytoxan) A. Hyponatremia B. Mental status changes C. Azotemia D. Bradycardia E. Weakness

A. HyponatremiA B. Mental status changeS E. Weakness Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.

Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? A. Increased blood urea nitrogen (BUN) B. Increased creatinine level C. Pale-colored urine D. Decreased sodium level

A. Increased blood urea nitrogen (BUN) An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.

7. A client with Parkinson disease is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A. Involving the client and his wife in developing a plan of care B. Setting up visitations by a home health nurse C. Telling his wife what the client needs D. Writing up a detailed plan of care according to standards

A. Involving the client and his wife in developing a plan of care Involving the client and spouse in developing a plan of care is the best way to ensure success with the management plan. Home health nurse visitations are generally helpful, but may not be needed for this client. Instructing the spouse about the client's needs and providing the spouse with a written plan of care do not reinforce the spouse's involvement and buy-in with the management plan.

13. The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A. Monitor weight B. Trend red blood cells and hemoglobin and hematocrit C. Monitor platelets D. Observe for motor deficits

A. Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.

The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Angiotensin-converting enzyme (ACE) inhibitors C. Opiates D. Calcium channel blockers

A. Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular filtration rate and blood flow within the kidney.

While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Obtain the client's pre-hemodialysis weight. B. Check the arteriovenous (AV) fistula for a thrill and bruit. C. Document the amount the client drinks throughout the shift. C. Auscultate the client's lung sounds every 4 hours. D. Explain the components of a low-sodium diet.

A. Obtain the client's pre-hemodialysis weight. C. Document the amount the client drinks throughout the shift. Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN.

8. In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Patent airway B. Indication of allergies C. Level of consciousness D. Loss of sensation

A. Patent airway Clients with injuries at or above T6 are at risk for respiratory complications. After assessment of cardiorespiratory status, the level of consciousness must be assessed using the Glasgow Coma Scale. In the ED, determining allergies or loss of sensation is not the first priority in assessing the client with spinal cord injury.

19. A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes

A. Potential for injury related to chronic confusion and physical deficits The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. The rest of the problems are usually the result of long-term care and not a priority for a short hospital stay.

The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) A. Restricted protein B. Liberal sodium C. Restricted fluids D. Low potassium E.Low fat

A. Restricted protein C. Restricted fluids D. Low potassium Breakdown of protein leads to azotemia and increased blood urea nitrogen. Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.

A patient with end-stage kidney disease (ESKD) has this serum laboratory analysis: K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL What is the priority nursing intervention? A. Assess heart rate and rhythm. B. Implement seizure precautions. C. Assess the patient's respiratory status. D. Evaluate the patient's acid-base balance.

Answer: A Rationale: Patients with ESKD experience significant fluid and electrolyte imbalances that are managed with medications and dialysis. Hyperkalemia can be a life-threatening event. In patients with kidney disease, the myocardial response (heart rate and rhythm) to hyperkalemia should be assessed to effectively determine appropriate treatment. High sodium can increase the patient's risk for seizures, excessive fluid balance will negatively effect breathing, and patients with ESKD experience acid-base imbalances from an inability to synthesize bicarbonate.

True or False: Patients with diabetes who also have chronic kidney disease require less insulin to treat hyperglycemia than a patient with diabetes who does not have chronic kidney disease. A.True B. False

Answer: A (True) Rationale: The patient with diabetes who has chronic kidney disease (CKD) often requires reduced doses of insulin and/or antidiabetic drugs because the failing kidneys do not excrete or metabolize these drugs well. Thus the drugs are effective longer, increasing the risk for hypoglycemia.

As the patient is preparing to discharge, the patient should be taught to restrict which elements in her diet? (Select all that apply.) A. Potassium B. Phosphorus C. Calcium D. Protein E. Vitamins

Answer: A, B, D Sodium is restricted because it causes retention of fluids. Potassium is restricted to prevent dangerous cardiac dysrhythmias. Vitamins must be supplemented, not restricted. There is an inverse relationship between phosphorus and calcium; when phosphorus is high, calcium is low and should not be restricted.

Which clinical data requires immediate nursing intervention to prevent progression of acute kidney injury? A. Heart rate of 120 beats/min B. Blood pressure of 156/88 C. Urine specific gravity of 1.001 mm Hg D. Intake of 2000 mL and output of 1500 mL in the past 24 hours

Answer: C Rationale: Decreased urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage and early kidney failure. Normal urine specific gravity ranges from 1.002 to 1.028. Assessing the patient's perfusion status is also very important in the prevention and/or treatment of kidney disease. (Source: Accessed May 31, 2014, from www.nlm.nih.gov/medlineplus/ency/article/003587.htm.)

After dialysis, which instruction should the nurse provide to the student nurse who is helping to provide care for the patient? A. Expect the patient's blood pressure to be higher after dialysis. B. The patient's weight will most likely be increased after dialysis. C. Expect the patient's temperature to be higher after dialysis. D. The patient's clotting studies will need to be drawn after dialysis.

Answer: C The patient's temperature is elevated after dialysis because the dialysis machine warms the blood slightly. Weight and blood pressure should be decreased because excess fluid is removed during dialysis. Heparin is required during hemodialysis and increases clotting time. All invasive procedures should be avoided for 4 to 6 hours after dialysis.

The patient is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment? A. Calcium B. Multivitamin C. Atenolol (Tenormin) D. GlyBURIDE (DiaBeta)

Answer: C Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.

A 68-year-old woman has chronic kidney disease and a history of type 2 diabetes. Two weeks ago, she had surgery to place a vascular graft access for hemodialysis. Which precaution will the nurse follow to ensure the function of the AV graft? A. Insert an IV and run saline at 10 mL/hr. B. Keep the patient's arm elevated on two pillows. C. Monitor blood pressure and radial pulses in both arms. D. Check for a bruit and thrill by auscultation and palpation over the site.

Answer: D A positive bruit and thrill indicate good blood flow through the graft. A dialysis access should only be used for dialysis. IVs should not be started, nor should blood pressure be taken in the same arm where the access is located. Elevation of the arm will not ensure function of the graft.

The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure? A. "Should we filter air circulation?" B. "Can we use less radiographic contrast dye?" C. "Should we add low-dose dobutamine?" D. "Should we decrease IV rates?"

B. "Can we use less radiographic contrast dye?" Contrast dye is severely nephrotoxic, and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Pre-renal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.

6. The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."

B. "I must not miss meals." Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and should be eliminated until the triggers are identified.

11. A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."

B. "I must report any chest pain right away." Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression.

A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic? A. "I'll talk to the health care provider and have your name removed from the waiting list." B. "You sound frustrated with the situation." C. "You're right, the wait is endless for some people." D. "I'm sure you'll get a phone call soon that a kidney is available."

B. "You sound frustrated with the situation." Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.

10. The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A. Alopecia B. Allergy C. Fever D. Chills

B. Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab). Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.

12. When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? A. Recombinant erythropoietin (Procrit) B. Allopurinol (Zyloprim) C. Potassium chloride D. Radioactive iodine-131 (131I)

B. Allopurinol (Zyloprim) TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.

17. A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? A. Administer pain medication. B. Assess airway and breathing. C. Assist with ambulation. D. Check the client's ability to void.

B. Assess airway and breathing. Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing. Swelling from the surgery can narrow the trachea, causing a partial obstruction. Ambulation, administration of pain medication, and assessing the client's ability to void are important, but are not the highest priority.

9. The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several options to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client

B. Assuming that the client is not totally confused Never assume that the client with Alzheimer's is totally confused and cannot understand what is being communicated. Choices should be limited; too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place.

When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? (Select all that apply.) A. Check brachial pulses daily. B. Auscultate for a bruit every 8 hours. C. Teach the client to palpate for a thrill over the site. D. Elevate the arm above heart level. E. Ensure that no blood pressures are taken in that arm.

B. Auscultate for a bruit every 8 hours. C. Teach the client to palpate for a thrill over the site. E. Ensure that no blood pressures are taken in that arm.

Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? A. Consuming a low-calcium diet B. Avoiding peas, nuts, and legumes C. Drinking cola beverages only once daily D. Increasing dairy products enriched with vitamin D

B. Avoiding peas, nuts, and legumes Kidney failure causes hyperphosphatemia; this client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Calcium should not be restricted; hyperphosphatemia results in a decrease in serum calcium and demineralization of the bone. Cola beverages and dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

Which signs and symptoms indicate rejection of a transplanted kidney? (Select all that apply.) A. Blood urea nitrogen (BUN) 21 mg/dL, creatinine 0.9 mg/dL B. Crackles in the lung fields C. Temperature of 98.8° F (37.1° C) D. Blood pressure of 164/98 mm Hg E. 3+ edema of the lower extremities

B. Crackles in the lung fields D. Blood pressure of 164/98 mm Hg E. 3+ edema of the lower extremities Signs and symptoms of fluid retention (e.g., crackles in the lung fields and 3+ edema of the lower extremities) indicate transplant rejection. Increased blood pressure is also a symptom of transplant rejection. Increasing BUN and creatinine are symptoms of rejection; a BUN of 21 mg/dL and a creatinine of 0.9 mg/dL reflect normal values. Fever, not normothermia, is symptomatic of transplant rejection.

20. Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain

B. Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.

When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) A. Explain to the client that the colostomy is only temporary. B. Encourage the client to participate in changing the ostomy. C. Obtain a psychiatric consultation. D. Offer to have a person who is coping with a colostomy visit. E. Encourage the client and family members to express their feelings and concerns.

B. Encourage the client to participate in changing the ostomy. D. Offer to have a person who is coping with a colostomy visit. E. Encourage the client and family members to express their feelings and concerns. Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.

A client is receiving immune-suppressive therapy after kidney transplantation. Which measure for infection control is most important for the nurse to implement? A. Adherence to therapy B. Handwashing C. Monitoring for low-grade fever D. Strict clean technique

B. Handwashing The most important infection control measure for the client receiving immune-suppressive therapy is handwashing. Adherence to therapy and monitoring for low-grade fever are important, but are not infection control measures. The nurse should practice aseptic technique for this client, not simply clean technique.

29. The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose

B. Headaches C. Dizziness D. Diplopia Headaches, dizziness, and diplopia are adverse effects of carbamazepine because this drug affects the central nervous system. Carbamazepine does not cause alopecia and does not increase blood glucose; divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

28. A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up

B. Intravenous access D. Suction equipment at the bedside E. Siderails up Intravenous access is needed to administer medications. Suctioning equipment should be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? A. Diltiazem (Cardizem) B. Lisinopril (Zestril) C. Clonidine (Catapres) D. Doxazosin (Cardura)

B. Lisinopril (Zestril) Angiotensin-converting enzyme inhibitors such as lisinopril appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers such as diltiazem may indirectly prevent kidney disease by controlling hypertension, but are not specific to slowing progression of kidney disease. Vasodilators such as clonidine and doxazosin control blood pressure, but do not specifically protect from kidney disease.

18. The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? A. Dopamine hydrochloride (Inotropin) B. Nifedipine (Procardia) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt)

B. Nifedipine (Procardia) This client is experiencing autonomic dysreflexia, which is a neurologic medical emergency that causes severe hypertension and bradycardia; nifedipine (Procardia) is given to treat the elevated blood pressure. Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker that is used to treat severe chronic back pain and failed back surgery syndrome and is also used for clients with cancer, AIDS, and unremitting pain from other nervous system disorders.

16. Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A. Morphine B. Ondansetron (Zofran) C. Naloxone (Narcan) D. Diazepam (Valium)

B. Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Morphine is a narcotic analgesic or opiate; it may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only; lorazepam, another benzodiazepine, may be used for nausea.

9. Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Potential for injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction

B. Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.

Questions 1. The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the client's survival time

B. Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.

When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? A. Mild discomfort at the insertion site B. Temperature 100.8° F C. 1+ ankle edema D. Anorexia

B. Temperature 100.8° F Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen may result in anorexia, nausea, and vomiting.

20. The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 on a 0-to-10 scale. B. The client is reporting difficulty swallowing secretions. C. The client has numbness and tingling bilaterally down the arms. D. Serosanguineous fluid oozes onto the neck dressing.

B. The client is reporting difficulty swallowing secretions. Difficulty swallowing may indicate swelling in the neck and the potential for compromise of the client's airway. Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

23. The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes The young adult client who is experiencing repeated seizures over the course of 30 minutes is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention; these are not medical emergencies. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

23. The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) A. "Standing for long periods of time will help to prevent low back pain." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes."

C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes." Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects; this method will help prevent back injury. Wearing high-heeled shoes can increase back strain. The client should avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight should be kept within 10% of ideal body weight.

2. Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I may lose my hair during this treatment." B. "I must be positioned in the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company."

C. "I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

22. The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."

C. "It delays the destruction of acetylcholine by acetylcholinesterase." By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system, thus delaying the onset of cognitive decline in some clients. Donepezil is not a serotonin reuptake inhibitor. It is a cholinesterase inhibitor and does not work on the protein beta amyloid, nor does it work on dopamine receptors.

8. The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."

C. "Make sure you take some time off and take care of yourself too." This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan is not a helpful response. A better response would be, "Take one day at a time." Suggesting that the spouse's comment was not nice is judgmental and inappropriate.

15. The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? A. "I will die early." B. "I will have gradual deterioration with no healthy times." C. "Parts of my nervous system have plaques." D. "This was caused by getting too many x-rays as a child."

C. "Parts of my nervous system have plaques." MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system. The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.

Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? A. "I can stop my medications when my kidney function returns to normal." B. "If my urine output is decreased, I should increase my fluids." C. "The anti-rejection medications will be taken for life." D. "I will drink 8 ounces of water with my medications."

C. "The anti-rejection medications will be taken for life." Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immunosuppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take anti-rejection medication with 8 ounces of water.

17. A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A. A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr

C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.

13. A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A. Administer phenytoin (Dilantin). B. Draw the client's blood. C. Assess the need for additional support. D. Start an intravenous (IV) line.

C. Assess the need for additional support. The primary goal is to assess the client for the need of additional support during the seizure. Interventions to protect the client from injury, turning the client on the side, and monitoring the client are indicated. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation.

14. Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds in 1 day

C. Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.

10. A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache

C. Classic migraine The client's symptoms match those of a classic migraine. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours.

A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? A. Blood pressure of 118/78 mm Hg B. Weight loss of 3 pounds during hospitalization C. Dyspnea and anxiety at rest D. Central venous pressure (CVP) of 6 mm Hg

C. Dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss.

27. The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk

C. Grapefruit juice Grapefruit juice can interfere with the metabolism of phenytoin. Apple juice, grape juice, and milk do not interact with phenytoin.

22. A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing.

C. Help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important, but will not immediately reduce blood pressure.

3. When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A. Drug toxicity B. Polycythemia C. Infection D. Dose-limiting side effects

C. Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .

7. When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions have resolved

C. Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.

A client admitted to the medical unit with a history of vomiting and diarrhea and an increased blood urea nitrogen requires 1 liter of normal saline infused over 2 hours. Which staff member should be assigned to care for the client? A. RN who has floated from pediatrics for this shift B. LPN/LVN with experience working on the medical unit C. RN who usually works on the general surgical unit D. New graduate RN who just finished a 6-week orientation

C. RN who usually works on the general surgical unit The nurse with experience in taking care of surgical clients will be most capable of monitoring the client receiving rapid fluid infusions, who is at risk for complications such as pulmonary edema and acute kidney failure. The pediatric float RN and the new graduate RN will have less experience in caring for this type of client. The LPN/LVN should not be assigned to a client requiring IV therapy and who is at high risk for complications.

11. Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A. Frequent ambulation B. Encouraging nutrition C. Regular turning and re-positioning D. Special pressure-relief devices

C. Regular turning and re-positioning Regular turning and re-positioning are the best way to prevent complications of immobility in clients with spinal cord problems. Frequent ambulation may not be possible for these clients. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Use of special pressure-relief devices is important, but is not the best way to prevent immobility complications in clients with spinal cord problems.

3. A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association

C. Safe Return Program The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.

10. In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A. Gait B. Mobility C. Sensation D. Strength

C. Sensation Both extremities may be checked for sensation by using a pin or paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side. Gait is assessed by having the client walk. Mobility is assessed by determining the client's level of self-care. Strength is measured by having the client perform bilateral grips.

21. The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

C. The client's chest moves very little with each respiration. Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm. Symptoms often worsen after injury because of swelling. Bradycardia is consistent with spinal shock and will need to be addressed, but this is not the nurse's first priority. Flaccid paralysis below the level of injury will need to be addressed, but this is not compromising the client's cardiopulmonary status. Systolic blood pressure remaining at 80 mm Hg is consistent with spinal shock and will need to be addressed, but this is not the first priority.

6. The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A. The student scrubs the hub of IV tubing before administering an antibiotic. B. The nurse overhears the student explaining to the client the importance of handwashing. C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. D. The nurse observes the student providing oral hygiene and perineal care.

C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.

While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? A. Instruct the client to deep-breathe and cough. B. Document the effluent as output. C. Turn the client to the opposite side. D. Re-position the catheter.

C. Turn the client to the opposite side. With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the peritoneal cavity for a specified time, then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the client's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, re-position the client to stimulate inflow or outflow. Turning the client to the other side or ensuring that he or she is in good body alignment may help. Instructing the client to deep-breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should re-position the client first to assist with complete dialysate drainage. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician re-positions a displaced catheter.

11. The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A. Monitoring platelets B. Administering packed red blood cells C. Using strict aseptic technique to prevent infection D. Administering low-dose heparin therapy for clients on bedrest

C. Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

Which factor represents a sign or symptom of digoxin toxicity? A. Serum digoxin level of 1.2 ng/mL B. Polyphagia C. Visual changes D. Serum potassium of 5.0 mEq/L

C. Visual changes Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5 to 2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.

19. The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? A. "Riluzole should be taken with food." B. "I plan to take riluzole once daily." C. "I will call the health care provider if my pulse goes below 50." D. "I will need frequent checks of my liver enzymes."

D. "I will need frequent checks of my liver enzymes." Riluzole (Rilutek) may cause liver toxicity, and liver enzymes will need to be checked frequently. This drug should be taken twice a day without food and when the stomach is empty. Riluzole may cause tachycardia, not bradycardia.

13. The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Begin driving 1 week after discharge." B. "Avoid using a pillow under the head while sleeping." C. "Swimming is recommended to keep active." D. "Keep straws available for drinking fluids."

D. "Keep straws available for drinking fluids." Keeping straws available makes it easier to drink fluids because the device makes it difficult to bring a cup or a glass to the mouth. Driving should be avoided because vision is impaired with the device. The head should be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Swimming should be avoided to prevent the risk for infection

9. A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A. "Every injury is different, and it is too soon to have any real answers right now." B. "Only time will tell." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the health care provider."

D. "Please request a meeting with the health care provider." Questions concerning prognosis and potential for recovery should be referred to the health care provider. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

A client is being treated for kidney failure. Which statement by the nurse encourages the client to express his or her feelings and concerns about the risk for death and the disruption of lifestyle? A. "All of this is new. What can't you do?" B. "Are you afraid of dying?" C. "How are you doing this morning?" D. "What concerns do you have about your kidney disease?"

D. "What concerns do you have about your kidney disease?" Asking the client about any concerns is open-ended and specific to the client's concerns. Asking the client to explain what he or she can't do implies inadequacy on the client's part. Asking the client if he or she is afraid of dying is too direct and would likely cause the client to be anxious. Asking the client how he or she is doing is too general and does not encourage the client to share thoughts on a specific topic.

8. A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A. Explain that this occurs in some clients and is usually permanent. B. Inform the client that a small glass of wine may help her relax. C. Protect the client from infection. D. Allow the client an opportunity to express her feelings.

D. Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.

The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply.) A. Heavy menses B. Smooth facial skin C. Hyperkalemia D. Breast tenderness E. Weight loss F. Deep vein thrombosis

D. Breast tenderness F. Deep vein thrombosis Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.

Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? A. Hematocrit of 26.7% B. Potassium within normal range C. Absence of spontaneous fractures D. Less fatigue

D. Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia.

12. A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client

D. Log rolling the client Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight. The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

2. A client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Suggesting that the client obtain assistance in performing activities of daily living (ADLs) D. Monitoring the client's sleep patterns

D. Monitoring the client's sleep patterns Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving). Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD should avoid watching his or her feet when walking to prevent falls and should be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.

5. A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A. Hospital library B. Internet C. Provider's office D. National Spinal Cord Injury Association

D. National Spinal Cord Injury Association The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting. The hospital library is not typically consumer-oriented; most information available there is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. The health care provider's office typically does not provide information about spinal cord injury support groups.

1. A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential

D. Positioning the client to maximize ventilation potential Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm. Although assessing bowel sounds is important as a sign of neurogenic shock, this is not the priority intervention on admission. Bladder retraining begins as necessary after evaluation of urinary function; a catheter is initially inserted. Monitoring nutritional status is essential only after stabilization from the acute injury.

14. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Restrains the client. D. Positions the client on the side.

D. Positions the client on the side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. Documenting the length and time of seizures is important, but not the first priority intervention. Forcing a tongue blade in the mouth can cause damage. Restraining the client can cause injury.

Which problem excludes a client hoping to receive a kidney transplant from undergoing the procedure? A. History of hiatal hernia B. Presence of diabetes and glycosylated hemoglobin of 6.8% C. History of basal cell carcinoma on the nose 5 years ago D. Presence of tuberculosis

D. Presence of tuberculosis Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation; these conditions worsen with the immune suppressants that are required to prevent rejection. A client with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point, and would not exclude the client from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation.

19. An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A. Storing drugs in dark locations at room temperature B. Wearing soft clothing C. Wearing a hat and sunglasses when going outside D. Reducing all direct and indirect sources of light

D. Reducing all direct and indirect sources of light Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy; it can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties; drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light; texture is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.

2. To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy

D. Respiratory therapy A client with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? A. Pulse oximetry reading of 95% B. Sinus bradycardia, rate of 58 beats/min C. Blood pressure of 148/90 mm Hg D. Temperature of 101.2° F (38.4° C)

D. Temperature of 101.2° F (38.4° C) Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever.

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) A. Assess for fever. B. Observe for bleeding. C. Administer pegfilgrastim (Neulasta). D. Do not permit fresh flowers or plants in the room. E. Do not allow the client's 16-year-old son to visit. F. Teach the client to omit raw fruits and vegetables from the diet.

A. Assess for fever. C. Administer pegfilgrastim (Neulasta). D. Do not permit fresh flowers or plants in the room. F. Teach the client to omit raw fruits and vegetables from the diet. Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.

15. A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A. Assessing neurologic status at least every 2 to 4 hours The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure, such as decreased level of consciousness. Decreasing environmental stimuli is helpful for the client with bacterial meningitis, but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. Assessing fluid balance while preventing overload is not the highest priority.

17. A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association

A. Assigning a case manager Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Ensuring all questions are answered and providing a safe environment are necessary for family support, but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral, but is not relevant for continuity of care.

A client with a recently created vascular access for hemodialysis is being discharged. In planning discharge instructions, which information does the nurse include? A. Avoiding venipuncture and blood pressure measurements in the affected arm B. Modifications to allow for complete rest of the affected arm C. How to assess for a bruit in the affected arm D. How to practice proper nutrition

A. Avoiding venipuncture and blood pressure measurements in the affected arm Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The arm should be exercised to encourage venous dilation, not rested. The client can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The nurse should take every opportunity to discuss nutrition, even as it relates to wound healing, but loss of the graft or fistula by compression or occlusion must take priority because lifesaving dialysis cannot be performed.

26. The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism

A. Bipolar disorder Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder. Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

22. When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor

A. Bruises C. Petechiae D. Epistaxis Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.

3. In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Chair pad B. Thromboembolism-deterrent (TED) hose C. Trapeze D. Water bottle

A. Chair pad In addition to regular turning and re-positioning, special pressure-relief devices such as chair pads may be used in the wheelchair to prevent pressure ulcers in the client with spinal cord injury. TED hose help prevent thrombus, not pressure ulcers. A trapeze helps the client reposition him- or herself; it is not a pressure-relief device. A water bottle is not indicated for the client with spinal cord injury.

24. A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation

A. Chest tightness Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing. Clients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.