MY QUESTIONS + Adult Health HESI review questions

18. Which action should the nurse take when caring for a client who is suspected as having the Ebola Virus a. Consider cohorting the client b. Wear a face mask and gown at all times c. Follow standard and droplet precautions d. Avoid contact with all body fluids and discharges

d. Avoid contact with all body fluids and discharges

10. A nurse working in a catholic hospital discourages clients from using contraceptives per hospital policy. Which category of ethics is the nurse following? a. Societal ethics b. Research ethics c. Professional ethics d. Organizational ethics

d. Organizational ethics

PPE Doff order

first untie gown 1. gloves 2. goggles or face shield 3. gown 4. mask or respirator 5. wash hands

ventricular fibrilation

is a life-threatening emergency

FULL PPE dawn order

personal protective Equipment (NO SKIN CONTACT to get contaminate yourself) 1) Hand hygiene 2) gown 3) mask/goggles 4) gloves over sleeves

7.The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

ANS: B Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L.

15.In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis

ANS: B A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be aԨected by alcohol consumption). Burn patients frequently experience extracellular Ԩuid volume deԨcit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.

12.A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

ANS: B The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

3.A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply Ԩrm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

ANS: B, E, F The nurse should stop the infusion before removing the IV catheter, so the Ԩuid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not Ԩrm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.

19.The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

ANS: C The patient is in Ԩuid overload. Raising the head of the bed to ease breathing is the Ԩrst action. OԨering calcium-rich foods is for hypocalcemia, not Ԩuid overload. Administering a diuretic is the second action. Increasing Ԩuids is contraindicated and would make the situation worse.

22.The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

ANS: C An eԨective measure of Ԩuid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of Ԩuid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deԨcit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

26.The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease

ANS: C Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is inԨuenced by many factors, including extracellular Ԩuid volume. A large dilute urine output can cause further hypernatremia.

33.A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

ANS: D A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended.

40.The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

ANS: D Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances.

37.A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.

ANS: D The nurse should Ԩrst attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

5.A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the Ԩrst one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

ANS: D The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure.

41.Which assessment Ԩnding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reԨexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

ANS: D This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deԨcit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reԨexes are related to hypercalcemia or hypermagnesemia.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D. Administer IV fluids.

Answer- A Rationale- A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? A. Change in level of consciousness B. Increasing muscular weakness C. Changes in pupil size bilaterally D. Progressive nuchal rigidity

Answer- A Rationale- A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C. Abdominal cramping D. Dry mucous membranes

Answer- A Rationale- A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately. Options B, C, and D are also findings that require intervention by the nurse but are of less priority than option A. Option B may indicate a hypertensive condition but is not as acute a condition as peritonitis. Option C is an expected finding in clients with small bowel obstruction and may require medication. Option D indicates probable fluid volume deficit, which requires fluid volume replacement.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.

Answer- A Rationale- Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption."

Answer- A Rationale- Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise? A. Oral Care B. Bathing C. Foot Care D. catheter care

Answer- A Rationale- The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences.

Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.

Answer- A Rationale- ushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

Answer- A, D

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home.

Answer- B Rationale- A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl)

Answer- B Rationale- Because the client has chronic alcoholism, she is likely to have hypomagnesemia. Option B is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A and D increase the QT interval, which can cause the torsades to worsen. Option C is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia

Answer- B Rationale- Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow

Answer- B Rationale- Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia

Answer- B Rationale- Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

Answer- B Rationale- It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required

Answer- B Rationale- The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess

Answer- B Rationale- The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

Answer- B Rationale- The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition

Answer- B Rationale- The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties B. Sudden, stabbing, severe pain over the lip and chin C. Unilateral facial weakness and paralysis D. Difficulty in chewing, talking, and swallowing

Answer- B Rationale- Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). Option A would be characteristic of Ménière syndrome (cranial nerve VIII). Option C would be characteristic of Bell palsy (cranial nerve VII). Option D would be characteristic of disorders of the hypoglossal (cranial nerve XII).

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.

Answer- C Rationale- A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin

Answer- C Rationale- All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level.

Answer- C Rationale- In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

Answer- C Rationale- It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately take to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Answer- C Rationale- Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years.

Answer- C Rationale- Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

Answer- C Rationale- The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider.

Answer- D Rationale- Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood. A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks.

Answer- D, attend an ostomy support group within 2 weeks Rationale- Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

Answer- Sodium Rationale- Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

44. A client's arterial blood gas report indicates that the pH is 7.25, pco2 is 60 mm Hg and HCO3 is 26 which of the client should the nurse consider is most likely to exhibit these blood gas results? A) a 65 year old with pulmonary fibrosis B) a 24 year old with uncontrolled type 1 diabetes C) a 45 year old who has been vomiting for 3 days D) a 54 year old who takes sodium bicarbonate for indigestion

B) a 24 year old with uncontrolled type 1 diabetes

A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) Be open to people who are different. Have a curiosity about people. Become culturally competent. Interact with each person in the same way. Request nurses take care of patients with the same ethnicity. Always request an interpreter for people from other countries.

Be open to people who are different. Correct Have a curiosity about people. Correct Become culturally competent. Correct As a health professional, the nurse is expected to listen to, empathize with, and understand people. To fulfill this role, nurses must first be open to people who are different from them, have a curiosity about people, and begin a journey to being culturally competent.

A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted. Which finding should the nurse observe for during the immediate hours after insertion? Beck's triad. Burns around the site Hypothermia Cardiac arrhythmia.

Beck's triad. Pacemakers and implantable defibrillators both require wires to be placed into the heart muscle and can cause bleeding into the pericardial sac which causes a high risk for cardiac tamponade. Signs of Beck's triad include low arterial blood pressure, distended neck veins, and distant, muffled heart sounds and are indicative of cardiac tamponade.

What is digoxin

Blood pressure medication with high toxicity

48. A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention? A) "maintain elevation of both legs" B) "massage the legs when they are painful" C) "apply a hot water bottle to the legs" D) "check pulses in the legs regularly"

D) "check pulses in the legs regularly"

35. A client's blood pressure increases dramatically six hours after a femoralpopliteal graft. Which priority concern motivates the nurse to inform the primary healthcare provider? A) hypertension may cause the graft to occlude. B) hypervolemia may be the case of the hypertension C) extremely high blood pressure may cause a brain attack D) rapidly increasing blood pressure may rupture the graft

D) rapidly increasing blood pressure may rupture the graft

41. The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated, the nurse records the two blood pressures of 172/104 and 164/98. what is the appropriate nursing action in s response to these readings? A) refer the cite to a nutritionist after providing health teaching about a low sodium diet B) place the client in a recumbent position and call the paramedics for transport to the hospital C) talk with the client to assess whether there is stress in the client's life and refer to a counseling service. D) take the client's blood pressure in the other arm and then schedule a healthcare practitioner's apportionment for as soon as possible

D) take the client's blood pressure in the other arm and then schedule a healthcare practitioner's apportionment for as soon as possible

What is the result of end-stage renal disease

Elevated serum lipid levels

What is associated with end-stage renal disease

Hyperkalemia?

21. A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin. Select all that apply. a. Mask b. Gown c. Betadine d. Checklist e. Sterile gloves

a. Mask b. Gown d. Checklist e. Sterile gloves

33. What are the clinical manifestations of MI in women? Select all that apply. a. Anoxia b. Indigestion c. Unusual fatigue d. Sleep disturbance e. Tightness of the chest

b. Indigestion c. Unusual fatigue d. Sleep disturbance

What does a nurse understand by the term regulatory law as applied to the nursing practice? 1 Regulatory law provides fair and equitable treatment when civil wrongs or violations occur. 2 Regulatory law describes and defines the legal boundaries of the nursing practice within each state. 3 Regulatory law reflects the decisions made by administrative bodies such as the State Boards of Nursing. 4 Regulatory law results from judicial decisions made in courts based on the judgments of individual legal cases.

3 Regulatory law reflects the decisions made by administrative bodies such as the State Boards of Nursing.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.

Answer- B Rationale- A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units.Correct Answer: A

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr.Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.Correct Answer: D

MATCHING A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body's regulators to the function it provides. a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release 1.Antidiuretic hormone 2.Angiotensin II 3.Aldosterone 4.Atrial natriuretic peptide 5.Bicarbonate

1.Antidiuretic hormone---c. Reduces excretion of water 2.Angiotensin II--e. Vasoconstricts and stimulates aldosterone release 3.Aldosterone--b. Reduces excretion of sodium and water 4.Atrial natriuretic peptide--a. Increases excretion of sodium and water 5.Bicarbonate--d. Major buffer in the extracellular fluid

The nurse is developing a plan to minimize the risk of adrenal insufficiency for a patient who is receiving long-term glucocorticoid therapy. Which outcome should be included? 1 Patient obtains periodic ultrasound scans of adrenal glands. 2 Patient tapers blood pressure medications to avoid hypotension. 3 Patient increases daily intake of sodium for vascular expansion. 4 Patient increases or supplements dosage of glucocorticoid at times of stress.

4 Patient increases or supplements dosage of glucocorticoid at times of stress. Exogenous steroids inhibit the synthesis and release of endogenous steroids by the adrenals, and recovery is variable, taking from days to a year. Failure to increase or supplement doses at times of stress may be life-threatening. Increasing sodium intake and tapering blood-pressure medications could cause harm. Adrenal gland ultrasound scans are not a valid way to minimize adrenal insufficiency.Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.

Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A. Fall prevention interventions C. Encouraging increased fluid intake D. Monitoring for constipation Severe hypercalcemia causes lethargy, which creates a risk for falling and constipation. Increased fluid intake is important to prevent renal calculi (kidney stones) during hypercalcemia

Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.) Fall prevention interventions Teaching regarding sodium restriction Encouraging increased fluid intake Monitoring for constipation Explaining how to take daily weights

A. Fall prevention interventions D. Monitoring for constipation Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. It also causes gastrointestinal smooth muscle weakness, which produces constipation.

24.A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

ANS C Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic.

27.The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

ANS: A Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375.

16.A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal

ANS: A The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.

34.The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

ANS: A The nurse will see the patient with D W and blood to prevent a medication error. When preparing to administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O. Type O is considered the universal donor. A patient with a mastectomy should have the IV in the other arm. Potassium chloride should be diluted, and it is never given IV push.

38.A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

ANS: A The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.

31.A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

ANS: A The total Ԩuid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deԨcit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net Ԩuid volume is equal.

2.Which assessments will alert the nurse that a patient's IV has inԨltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

ANS: A, C, F InԨltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis. Infiltration. Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue. Infiltration can be caused by improper placement or dislodgment of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel lumen.

1.A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

ANS: A, C, F The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the non-dominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

28.A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

ANS: B Physical examination findings of deԨcit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid.

25.A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

ANS: B Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium.

11.A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: B Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that aԨect metabolic acids.

14.A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment Ԩnding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

ANS: B Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.

36.A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

ANS: C Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood.

42.While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of Ԩuids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

ANS: C The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of Ԩuids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient.

3.The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

ANS: C Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of Ԩuid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inԨammation or malnutrition. Concentration pressure is not a nursing term.

39.A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A Ԩlter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

ANS: C When administering a transfusion you need an appropriate-size IV catheter and blood administration tubing that has a special in-line Ԩlter. The patient's blood should not be mixed with the infusion blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.

A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline.

Answer, D Rationale- Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101° F D. Absence of chest tube drainage for 2 days

Answer- A Rationale- Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.

An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.

Answer- B Rationale- All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.

Answer- B Rationale- The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib

Answer- C

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Sodium B. Phosphate C. Potassium D. Glucose

Answer- C Rationale- Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is normal or elevated, depending on the amount of water resorbed with the sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes.

Answer- D Rationale- Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy.

Answer- D Rationale- Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

Answer- D Rationale- Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected

Answer- D Rationale- The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require option A. Although option B is helpful information, it does not have the priority of option D. A Hemovac is used to drain fluid from a dead space and is not a determinant for the room assignment.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia

Answer- D Rationale- The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

43. when an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? A) interview the client for a health history B) assess the client's heart and lung sounds C) monitor the client's pulse and temperature D) obtain the client's blood specimen for electrolytes

B) assess the client's heart and lung sounds

The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures for the client. Which pathologic changes in the client is causing the ventilator alarms? Decreased lung compliance. Increased respiratory rate. Low volume of expired air. High tidal volumes.

Decreased lung compliance. The inflammatory response in the ARDS causes changes in lung compliance. ARDS causes a decreased lung compliance, or stiffer lung, which causes the high peak airway pressures and frequent ventilator alarms.

$$The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? When did you have your last alcoholic drink? How does alcohol usually affect you? What is your favorite alcoholic drink? Have you ever felt guilty about your drinking?

Have you ever felt guilty about your drinking? The CAGE questionnaire can be used to screen clients for excessive or uncontrolled drinking. CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. To assess for possible alcohol abuse, the nurse should ask if the client has ever felt guilty about drinking.

What can insulin do?

Increase serum potassium level (and blood glucose of course)

The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse? Increased pulmonary secretions. Intercostal muscle retraction Decreased breath sounds. Bronchovesicular breath sounds.

Intercostal muscle retraction Intercostal muscle retraction is a critical sign of respiratory muscle fatigue that is likely to lead to acute respiratory failure, requiringintubation withmechanical ventilation. The ABG results reveal respiratory alkalosis as evidenced by an increased pH and decreased PaCO2 with a normal HCO3.

$$The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? Elevate head of bed 30 degrees to percuss the spleen. Palpate the splenic borders before percussing. Percuss the splenic area as the client takes a deep breath. Place client in a Trendelenburg position to isolate the spleen.

Percuss the splenic area as the client takes a deep breath. If the spleen is enlarged due to an infection or trauma, tympany changes are noted with dullness upon inspiration.

$$The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? Press the tongue down one side at a time with a tongue depressor. Ask the client to open the mouth and say "ah." Listen for hoarseness after asking the client to speak. Palpate the neck and ask the client to swallow.

Press the tongue down one side at a time with a tongue depressor. When assessing the posterior pharynx, a tongue depressor should be used to press down one side of the tongue at a time to avoid stimulating the gag reflex.

$$he client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps? Enlargement centered along the anterior lower neck region. Swelling anterior to the ear lobe on one side of the face. Generalized rounded shape of the face. Paralysis on one side of the face.

Swelling anterior to the ear lobe on one side of the face. The parotid salivary gland is not normally palpable, but the mumps infection may cause swelling and tenderness of these glands. The swelling of the parotid glands can be either unilateral or bilateral in appearance. When a client reports recent exposure to mumps, the nurse should check for parotid tenderness by palpating in a line from the outer corner of the eye to the lobule of the ear.

Signs of hyperkalemia

Tall/spiked T waves, prolonged QT interval, widening QRS wave

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).Correct Answer: C

$$ The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? The client works in a daycare setting that has had a scabies outbreak The client has been using a chemical stripping agent for home remodeling. The client has a family history of psoriasis in both parents and a sibling. The client routinely works with clay and paint as a hobby

The client works in a daycare setting that has had a scabies outbreak Scabies is a highly contagious condition that causes pruritus, small papules, vesicles and burrows in the skin as the scabies mite burrows into the superficial layer of the skin to lay her eggs. Scabies is often spread among children and others in close contact.

$$The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? The left leg internally rotates. The left leg rises off of the table. The left leg remains on the table. The left leg externally rotates.

The left leg rises off of the table The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table, when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative.

$$The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? Tap the liver's boundaries lightly with a percussion hammer to produce a sound. Push gently using fingers of both hands to determine the boundaries of the liver. Use a bouncing motion to tap the middle finger placed within boundaries of the liver. Cup hands and clap with alternating contact with the skin over regions of the liver.

Use a bouncing motion to tap the middle finger placed within boundaries of the liver. Percussion is a tapping techniques done with short, sharp strokes to assess underlying structures, such as the liver which is solid and should have a dull sound. When percussing the liver for abnormal sounds, the middle finder of dominant hand is used to tap with a bouncing motion on the opposite middle finder that is placed within the boundaries of the liver, which if diseased is no longer dense and does not reveal a dull sound.

$$Which question should the nurse ask in order to test a client's remote memory? What is your date of birth? Who is your current healthcare provider? What medications are you taking? How did you arrive at the hospital today?

What is your date of birth? Cognition is typically evaluated in a rapid and focused manner and includes the assessment of memory. Remote memory, or long-term memory, can be tested by asking the client's date of birth.

$$A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? You have benign fibroid tumors, a common occurrence in women your age. This is a sign of uterine cancer and I will report this to the healthcare provider. This is a sign of endometriosis, so we will need to biopsy the lesions. This is a very common finding in pregnancy and it will go away.

You have benign fibroid tumors, a common occurrence in women your age. Correct With myomas (uterine fibroids), subjective findings are varied depending on the size and location of the lesions. Often there are no symptoms. Symptoms that may occur include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs endometrium. Objective findings: uterus irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall. These benign tumors are common; by age 50 years 70% of White women and greater than 80% of Black women will have at least one.Jarvis (2016). Physical Examination and Health Assessment, 7th ed., p. 764.

Which are the elements of discovery of a lawsuit? Select all that apply. a. Experts b. Medical records c. Proof of negligence d. The depositions of witnesses e. Petition elements of the claim

a. Experts b. Medical records d. The depositions of witnesses

29. An adolescent who had the diagnosis of conduct disorder since the age of 9 ... a. Preventing violence b. Encourage insight c. Supporting self-esteem d. Promoting social interaction

a. Preventing violence

22. A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? a. Spread the client's feet away from each other. b. Move the client on the count of three. c. Instruct the client to flex the muscles of the internal girdle. d. Stand close to the client when assisting with the move.

a. Spread the client's feet away from each other.

An aldosterone blocking agent would result in which of the following manifestations? a. hyperklemia b. hypernatremia c. water retention d. vasoconstriction

a. hyperklemia when ALDOSTERONE released by RAAS cascade, it holds onto sodium and gets rid of potassium; if you BLOCK aldosterone, sodium will go away and potassium will stay

17. Which school-age developmental characteristic increases the client's risk for poisoning? Select all that apply. a. Trying new things b. Adhering to group rules c. Increasing independence d. Being easily influenced by peers e. Having a strong allegiance to friends

b. Adhering to group rules d. Being easily influenced by peers e. Having a strong allegiance to friends

What principal components are associated with a nurse's time management skill? Select all that apply. a. Autonomy b. Goal setting c. Priority setting d. Interruption control e. right communication

b. Goal setting c. Priority setting d. Interruption control

12. What is the role of a nurse administrator in a healthcare setting? a. Providing surgical anesthesia under the guidance and supervision of anesthesiologist b. Preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development c. Providing comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions d. Providing knowledge about current nursing practices, trends, theories and necessary skills in labs and clinical settings

b. Preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development

24. A client is being treated for influenzas A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which client statement indicates a need for further instruction? a. "I should practice respiratory hygiene/cough etiquette." b. "I should avoid contain with the elderly or children" c. "I should obtain pneumococcal vaccination each year." d. "I should allow visitors for short periods of time only."

c. "I should obtain pneumococcal vaccination each year."

❥1. Which are extrinsic factors responsible for falls in older adults? Select all that apply. a. Impaired vision b. Cognitive impairment c. Environmental hazards d. inappropriate footwear e. Improper use of assistive devices

c. Environmental hazards d. inappropriate footwear e. Improper use of assistive devices

❥1. Which intervention would be most beneficial in preventing a catheter-associated UTI in a postoperative patient? a. Pouring warm water over the perineum b. Ensuring the patency of the catheter c. Removing the catheter w/in 24 hrs d. Cleaning the catheter insertion site

c. Removing the catheter w/in 24 hrs

What is the result of diabetic ketoacidosis (DKA)

ketonuria