NMNC 4510 Concept Synthesis

The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? 1) The partial pressure of oxygen (PO2) value is 80 mm Hg. 2) The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. 3) The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). 4) Serum potassium value is 4 mEq/L (4 mmol/L).

3) The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L).

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? 1) Slow heart rate 2) Cool skin temperature 3) Bounding radial pulses 4) Increased urine output

2) Cool skin temperature

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort? 1) Side-lying with head elevated 45 degrees 2) Sims with head elevated 90 degrees 3) Semi-Fowler with legs elevated 4) High Fowler using the bedside table to rest the arms

4) High Fowler using the bedside table to rest the arms

Which equipment would the nurse recommend to foster independence at home for an ambulatory client who has Parkinson disease? A raised toilet seat Side rails for the bed Crutches for ambulation A trapeze above the bed

A raised toilet seat

Which hormone influences kidney function? 1. Renin 2. Bradykinin 3. Aldosterone 4. Erythropoietin

Aldosterone Rationale: Released from the adrenal cortex, aldosterone influences kidney function. Renin, bradykinin, and erythropoietin are kidney hormones.

Which clinical findings would the nurse anticipate for a client who has an exacerbation of multiple sclerosis? SATA Double vision Resting tremors Flaccid paralysis Scanning speech Intellectual disability

Double vision Scanning speech

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? Deep breathing Hoarse quality to the voice Pink-tinged, frothy sputum Rapid abdominal breathing

Hoarse quality to the voice

Which findings would the nurse expect when completing an admission physical for a client with a diagnosis of Parkinson disease? SATA Muscle rigidity Blank facial expression Leaning toward the affected side Intention tremors with movement Hyperextension of the affected extremity

Muscle rigidity Blank facial expression

Which assessment finding presents the highestrisk for cardiac shock? 1) Pulse 104 beats/minute 2) Respirations 22 breaths/minute 3) Temperature 98.9°F (37.2°C) 4) Blood pressure 114/68 mm Hg

1) Pulse 104 beats/minute

The nurse is teaching a student nurse about the ongoing monitoring of a client with electrical burns. Which statement made by the student nurse indicates the need for further teaching? "I should monitor the airway." "I should monitor the eye pH." "I should monitor vital signs." "I should monitor urine output."

"I should monitor the eye pH."

A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, "Am I going to die?" Which response would the nurse make? "Most individuals with your disease live a normal life span." "Is your family here? I would like to explain your disease to all of you." "The prognosis varies, as most individuals have remissions and exacerbations." "Why don't you speak with your health care provider to get more details?"

"The prognosis varies, as most individuals have remissions and exacerbations."

When the nurse obtains vital signs of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client who is receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which nursing action would be the priority? 1) Give naloxone intravenously per protocol. 2) Assess the client's pain level on a 10-point scale. 3) Document the vital signs in the client record. 4) Notify the hospital rapid response team.

1) Give naloxone intravenously per protocol.

A client who sustained serious burns now has a stress ulcer. If complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? SATA 1) Weakness 2) Diaphoresis 3) Tachycardia 4) Cold extremities 5) Flushed skin tone

1) Weakness 2) Diaphoresis 3) Tachycardia 4) Cold extremities

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). Which action would the nurse take to reduce the possibility of retinopathy of prematurity? 1) Humidifying oxygen flow to prevent dehydration 2) Uncovering the entire body to increase exposure to the oxygen 3) Applying eye patches to both eyes to protect them from the oxygen 4) Verifying oxygen saturation frequently to adjust flow on the basis of need

4) Verifying oxygen saturation frequently to adjust flow on the basis of need

Which wound care is given to a client with severe burn injuries during the acute phase? Assess extent and depth of burns. Provide daily shower and wound care. Remove dead and contaminated tissue. Assess the wound daily and adjust the dressing.

Assess the wound daily and adjust the dressing.

A client with myasthenia gravis has been receiving neostigmine and asks about its action. Which information would the nurse consider when formulating a response? Stimulates the cerebral cortex Blocks the action of cholinesterase Replaces deficient neurotransmitters Accelerates transmission along neural sheaths

Blocks the action of cholinesterase

A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? 1. Acidosis 2. Calcium depletion 3. Potassium retention 4. Sodium chloride depletion

Calcium depletion Rationale: In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.

A client with Parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of Parkinson disease? Carbidopa-levodopa Isocarboxazid Dopamine Pyridoxine (vitamin B6)

Carbidopa-levodopa

A client asks the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the client? Disintegration of the myelin sheath Breakdown of upper and lower neurons Reduced acetylcholine receptors at synapses Degeneration of neurons of the basal ganglia

Degeneration of neurons of the basal ganglia

A child being treated with cardiac medications developed vomiting, bradycardia, anorexia, and dysrhythmias. The nurse understands which medication toxicity is responsible for these symptoms? Digoxin Nesiritide Dobutamine Spironolactone

Digoxin Rationale: Digoxin helps improve pumping efficacy of the heart, but an overdose can cause toxicity leading to nausea, vomiting, bradycardia, anorexia, and dysrhythmias.

Arrange the order of airway management in a client with burns. Place the client on ventilatory support. Escharotomies of the chest wall, if necessary. Intubate the client within 1 to 2 hours after injury. Extubation is indicated when edema resolves.

Intubate the client within 1 to 2 hours after injury. Place the client on ventilatory support. Escharotomies of the chest wall, if necessary. Extubation is indicated when edema resolves.

Which diversion activity would the nurse encourage to meet the client's needs during the remission phase of his or her multiple sclerosis (MS)? Hiking Swimming Sewing classes Watching television

Swimming

Which nursing intervention would prevent septic shock in the hospitalized client? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures.

A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? 1) Bradycardia 2) Restlessness 3) Constricted pupils 4) Clubbing of the fingers

2) Restlessness

The charge nurse is communicating with the registered nurse about caring for a client with a respiratory disorder. Which instructions can be delegated to the registered nurse to provide effective care to the client? Select all that apply. One, some, or all responses may be correct. 1) "Feed the client three times a day." 2) "Change the client's clothes every 6 hours." 3) "Assess the client's respirations after 1 hour." 4) "Provide intravenous medication every 3 hours." 5) "Inform the licensed practical nurse if the respiration rate changes."

3) "Assess the client's respirations after 1 hour." 4) "Provide intravenous medication every 3 hours."

Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education? "I would administer intravenous analgesia." "I would prepare for an endotracheal intubation." "I would anticipate the need for a fiberoptic bronchoscopy." "I would immediately calculate the burned surface area with the rule of nines."

"I would immediately calculate the burned surface area with the rule of nines."

When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first? Ask the client about medication use and activity level at home. Suggest discharge to a local assisted living setting with the client. Teach the client about the importance of limiting home salt intake. Talk with the client about having home health visits after discharge.

Ask the client about medication use and activity level at home. Rationale: Further assessment of the client's home situation and possible reasons for frequent readmissions are needed before other actions can be taken.

Which action would be the nurse's first priority when receiving a client with major burns? Assessing airway patency Checking the client from head to toe Administering oxygen as needed Elevating the extremities if no fractures are noticed

Assessing airway patency

When assisting a client with Parkinson disease to ambulate, which instruction would the nurse provide the client? Avoid leaning forward. Hesitate between steps. Rest when tremors are experienced. Keep arms close to the center of gravity.

Avoid leaning forward.

A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity, 1.015; urine output, 50 mL/h; hematocrit, 42 (0.42 volume fraction); albumin, 3.6 g/dL (36 g/L); and pulmonary arterial wedge pressure, 10 mm Hg. Which conclusion would the nurse draw based on the laboratory results? Albumin is critically low. Fluid therapy is successful. Kidney failure is impending. Hemoconcentration is occurring.

Fluid therapy is successful.

Which organ-specific autoimmune disorder would the nurse associate with a client's kidney? 1. Graves disease 2. Addison disease 3. Goodpasture syndrome 4. Guillain-Barré syndrome

Goodpasture syndrome Rationale: Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves disease and Addison disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.

Which would the nurse consider the major characteristic of a cardiac malformation associated with left-to-right shunting? Increased hematocrit Severe growth delay Clubbing of the fingers and toes Increased blood flow to the lungs

Increased blood flow to the lungs Rationale: With a left-to-right shunt, blood flows through a defect in the ventricular wall of the heart and is shunted from the higher pressure left side to the lower pressure right side. The increased blood flow from the right ventricle results in an increased blood flow to the lungs. Polycythemia and an increased hematocrit are not common in children with a left-to-right shunt. Severe growth delay is not common in children with a left-to-right shunt. Clubbing is a more common finding in children with a right-to-left shunt.

The nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of this injury? Preventing pain Managing leukopenia Preventing infection Managing fluid loss

Managing fluid loss

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? Remove the client's clothing. Evaluate whether the client has inhaled smoke. Insert a venous access device in an unaffected arm. Determine the extent of the burns, using the rule of nines.

Evaluate whether the client has inhaled smoke.

Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? SATA Need for daily aspirin Symptoms of infection Use of pain medications Wound care for leg incision Purpose of anticoagulant medications

Symptoms of infection Use of pain medications Purpose of anticoagulant medications

A 50-year-old client who has aortic stenosis and is scheduled for a valve replacement tells the nurse, "I gave my spouse all my financial records in case I don't make it." Which response by the nurse is best? "Your surgeon is very experienced." "People your age generally do very well." "Are you concerned that you may die during surgery?" "Would you like medication to help you sleep at night?"

"Are you concerned that you may die during surgery?" Rationale: Asking if the client is concerned about dying is reflective and encourages further communication. A statement that the surgeon is experienced may be true, but is not specific to the client's statement and cuts off further communication. Telling the client that other people generally do well is nonspecific and provides false reassurance that is unlikely to decrease anxiety. Asking about whether the client would like sleep medication evades the client's concerns and cuts off more communication about the client's concerns.

A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed to address which purpose? 1. To correct hyperkalemia 2. To increase urinary output 3. To prevent respiratory acidosis 4. To increase serum calcium levels

To correct hyperkalemia Rationale: The 50% glucose and regular insulin infusion treats the hyperkalemia associated with kidney failure; it moves potassium from the intravascular compartment into the intracellular compartment. Insulin will not increase urinary output. Insulin is not a treatment for respiratory acidosis. Insulin and glucose do not increase serum calcium levels.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? Crackles in the lungs Decreased heart rate Decreased blood pressure Cyanosis of nailbeds

1 Crackles in the lungs

Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

1) Metabolic acidosis

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? SATA 1) Pallor 2) Agitation 3) Tachycardia 4) Narrow pulse pressure 5) Decreased respirations

1) Pallor 2) Agitation 3) Tachycardia 4) Narrow pulse pressure

Which clinical manifestations would the nurse observe in a client experiencing a full-blown anaphylactic shock from a type I latex allergic reaction? SATA 1) Stridor 2) Fissuring 3) Hypotension 4) Dyspnea 5) Cracking of the skin

1) Stridor 3) Hypotension 4) Dyspnea

A client develops acute respiratory distress syndrome (ARDS). The nurse assesses the client and notes signs of pulmonary edema and atelectasis. The findings correspond to which phase of ARDS? 1) Fibrotic 2) Exudative 3) Reparative 4) Proliferative

2) Exudative

The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? 1) Hypokalemia 2) Metabolic acidosis 3) Respiratory alkalosis 4) Decreased carbon dioxide level

2) Metabolic acidosis

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? 1) Urine output 1000 mL in 8 hours 2) Oral temperature 101°F (38.3°C) 3) Client report of feeling very thirsty 4) Bounding radial and femoral pulses

3) Client report of feeling very thirsty

A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? 1) Tremors 2) Anasarca 3) Bradypnea 4) Tachycardia

4) Tachycardia

Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body. Reduce protein intake to avoid overtaxing the kidneys. Administer the prescribed intravenous fluid with the added vitamin C.

Administer the prescribed intravenous fluid with the added vitamin C.

After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client who had a cardiac catheterization through the femoral artery? Apply pressure to the site. Obtain vital signs. Change the client's gown and bed linens. Assess the catheterization site.

Assess the catheterization site. Rationale: Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined, the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.

The nurse is assessing four different clients. Which findings show that the client is at risk for heart disease? Client 1: Red color assessed. Location assessed- face, area of trauma, sacrum, shoulders Client 2: Bluish color assessed. Location assessed- nail beds, lips, mouth, skin. Client 3: Pallor color assessed. Location assessed- Face, conjunctiva, nail beds, palms of hands. Client 4: Yellow orange color assessed. Location assessed- sclera, mucous membranes, skin.

Client 2 Rationale: Client 2 is at risk for heart disease because the nail beds, lips, mouth, and skin show cyanosis, or a bluish color. This may be due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease.

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication? Blocks the effects of acetylcholine Increases the production of dopamine Restores the dopamine levels in the brain Promotes the production of acetylcholine

Restores the dopamine levels in the brain

Corticosteroid therapy is prescribed for a client with multiple sclerosis. In response to the therapy, which symptom would the nurse expect to decrease? Emotional lability Muscular contractions Pain in the extremities Visual impairment

Visual impairment

A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client reports feeling depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. Which response would the nurse provide? 1. "The staff will provide total care, because the infection causes severe fatigue." 2. "Mood elevators will be prescribed to improve the depression and irritability." 3. "Vitamin B12 will be prescribed for the anemia, and the stools will be dark." 4. "Protein foods will be restricted so the kidneys can clear the waste products."

"Protein foods will be restricted so the kidneys can clear the waste products." Rationale: One of the kidney's functions is to excrete nitrogenous waste from protein metabolism; restriction of protein intake decreases the workload of the damaged kidneys. The client is encouraged to be as active and independent as possible. Medications are avoided because they may mask symptoms. Iron and folic acid supplements are used for anemia in chronic kidney disease; Vitamin B12 is used for pernicious anemia and does not make the stools dark; iron makes the stools dark.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? SATA 1) Bradycardia 2) Hypotension 3) Spastic paralysis 4) Urinary retention 5) Increased pulse pressure

1) Bradycardia 2) Hypotension 4) Urinary retention

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock? 1) Cold, clammy skin 2) Slow, bounding pulse 3) Increased blood pressure 4) Hyperactive bowel sounds

1) Cold, clammy skin

Which statement made by a student nurse indicates the need for further learning about assessing for respiratory system manifestations of alkalosis? Select all that apply. One, some, or all responses may be correct. 1) "I should assess for an increased rate of ventilation in respiratory alkalosis." 2) "I should assess for a decreased depth of ventilation in respiratory alkalosis." 3) "I should assess for a decreased rate of ventilation in respiratory alkalosis." 4) "I should assess for an increased depth of ventilation in respiratory alkalosis." 5) "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.

2) "I should assess for a decreased depth of ventilation in respiratory alkalosis." 3) "I should assess for a decreased rate of ventilation in respiratory alkalosis."

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and has hypovolemic shock. Which site(s) would be used to obtain the client's pulse rate? SATA 1) Apical 2) Carotid 3) Brachial 4) Femoral 5) Popliteal

2) Carotid 4) Femoral

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? 1) Respiratory alkalosis 2) Poor oxygen perfusion 3) Normal acid-base balance 4) Compensated metabolic acidosis

3) Normal acid-base balance

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? 1) Obstructive 2) Neurogenic 3) Cardiogenic 4) Hypovolemic

4) Hypovolemic

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1) Urticaria 2) Tachycardia 3) Restlessness 4) Laryngeal edema

4) Laryngeal edema

A client asks the nurse what causes myasthenia gravis. Which description of pathology would the nurse use in response to the client? A genetic defect in the production of acetylcholine (ACh) An inefficient use of the neurotransmitter ACh A decreased number of functioning acetylcholine receptor (AChR) sites An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

A decreased number of functioning acetylcholine receptor (AChR) sites

Which catecholamine receptor is responsible for increased heart rate? Beta-1 receptor Beta-2 receptor Alpha-1 receptor Alpha-2 receptor

Beta-1 Receptor Rationale: Beta-1 receptors are responsible for increased heart rate. Beta-2 receptors, alpha-1 receptors, and alpha-2 receptors are not present in the heart; therefore, they are not responsible for increasing the heart rate. Beta receptors are present in such organs as blood vessels, kidneys, bronchioles, and bladder. Alpha receptors are present in such organs as eyes, skin, and liver.

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis? Electromyography Pyridostigmine test Edrophonium chloride test History of physical deterioration

Edrophonium chloride test

Which term would the nurse use to document observing the characteristic gait associated with Parkinson disease? Ataxic Shuffling Scissoring Asymmetric

Shuffling

For which complications would the nurse monitor a client hospitalized with end-stage kidney disease? Select all that apply. One, some, or all responses may be correct. 1. Anemia 2. Dyspnea 3. Jaundice 4. Hyperexcitability 5. Hypophosphatemia

Anemia, Dyspnea Rationale: Anemia results from decreased production of erythropoietin by the kidneys, which causes decreased erythropoiesis by bone marrow. Dyspnea is a result of fluid overload, which is associated with chronic kidney failure. Jaundice occurs with biliary obstruction or liver disorders, not with kidney failure. Hyperphosphatemia occurs with kidney failure, not hypophosphatemia. Hyperexcitability is not a feature of end-stage kidney disease.

A client who has multiple sclerosis is admitted to the hospital with increasingly frequent and severe exacerbations. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which response would the nurse make? "You may be able to decrease your feelings of guilt by seeking counseling." "It would be helpful if you became involved in volunteer work at this time." "I recognize it's hard to deal with, but try to remember that this, too, shall pass." "Joining a support group of people who are coping with this situation may be helpful."

"Joining a support group of people who are coping with this situation may be helpful."

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider? 1. Acidic pH 2. Glucose negative 3. Bacteria negative 4. Presence of large proteins

Presence of large proteins Rationale: The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal; the nurse would report their presence to the primary health care provider to modify the client's treatment plan.

The nurse reviews the assessment findings of four clients with burns. Which client's findings are consistent with chemical burns? Client A - cardiac arrest Client B - minimal to absent pain Client C - paralysis Client D - hoarseness

Client C - paralysis

When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear? Stridor Crackles Wheezes Rhonchi

Crackles Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are typically heard with airway narrowing caused by asthma. Rhonchi are heard when airways are obstructed with thick secretions caused by problems such as pneumonia.

Which client has second-degree burns? Client A - waxy white, dark-brown appearance Client B - redness, pain, minimal edema Client C - moist blebs, blisters, severe pain Client D - dry, leathery eschar, absence of pain

Client C - moist blebs, blisters, severe pain

A client develops a transfusion reaction. Which clinical response will the nurse assess to determine kidney damage? 1. Glycosuria 2. Blood in the urine 3. Decreased urinary output 4. Acute pain over the kidney

Decreased urinary output Rationale: Diminished renal function usually is evidenced by a decrease in urine output to less than 100 to 400 mL/24 h. Glycosuria is unrelated to a transfusion reaction. Although blood in the urine and acute pain over the kidney are related to the renal system and are signs of an acute hemolytic reaction, their presence does not necessarily indicate that kidney damage has occurred.

Which complication is the most serious for a client with kidney failure? 1. Anemia 2. Weight loss 3. Uremic frost 4. Hyperkalemia

Hyperkalemia Rationale: Decreased glomerular filtration leads to hyperkalemia, which may cause lethal dysrhythmias such as cardiac arrest. Anemia may occur but is not the most serious complication and should be treated in relation to the client's clinical manifestation; erythropoietin and iron supplements usually are used. Weight loss alone is not life threatening. Uremic frost, a layer of urea crystals on the skin, causes itching, but it is not the most serious complication.

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? SATA Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea

Unusual fatigue Dependent edema Nocturnal dyspnea Rationale: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure.

A client who has chronic kidney failure is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the client indicates understanding of the therapy? 1. "It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2. "It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3. "It decreases the need for immobility because it clears toxins in short and intermittent periods." 4. "It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."

"It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." Rationale: Diffusion moves particles from an area of greater concentration to an area of lesser concentration; osmosis moves fluid from an area of lesser to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane to indirectly cleanse the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.

Which process is a function of the kidney hormones? 1. Prostaglandin increases blood flow and vascular permeability. 2. Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. 3. Renin raises blood pressure because of angiotensin and aldosterone secretion. 4. Erythropoietin promotes calcium absorption in the gastrointestinal tract tract.

Renin raises blood pressure because of angiotensin and aldosterone secretion. Rationale: Renin is a kidney hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. Prostaglandin is a kidney hormone that regulates intrarenal blood flow via vasodilation or vasoconstriction. Bradykinin is a kidney hormone that increases blood flow and vascular permeability. Erythropoietin is a kidney hormone that stimulates the bone marrow to make red blood cells.

A client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess? Select all that apply. One, some, or all responses may be correct. 1. Skin rash 2. Dehydration 3. Hypovolemia 4. Hyperkalemia 5. Metabolic acidosis

Dehydration, Hypovolemia Rationale: In the diuretic phase, excretion of fluids retained during the oliguric phase occurs and may reach 3 to 5 L daily; unless fluid replacement occurs, dehydration and hypovolemia is a potential. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase.

During the oliguric phase of acute kidney injury, for which abnormal finding would the nurse monitor in the client? 1. Hypothermia 2. Hyperphosphatemia 3. Hypocalcemia 4. Hypernatremia

Hyperphosphatemia Rationale: The kidneys retain potassium during the oliguric phase of acute kidney injury; an elevated potassium level is one of the main indicators for placing a client on hemodialysis when he or she is experiencing acute kidney injury. Hypothermia does not occur with acute kidney injury. Serum levels of phosphorus decrease during the oliguric phase of kidney failure. The retained fluids create a hemodilution effect and hyponatremia occurs, not hypernatremia.

Cardiac catheterization in a child with a ventricular septal defect (VSD) serves which purpose? Identifies the specific location of the defect Confirms the presence of a pansystolic murmur Reveals the degree of cardiomegaly that is present Establishes the presence of ventricular hypertrophy

Identifies the specific location of the defect Rationale: Cardiac catheterization visualizes the exact location of the ventricular septal defect; also, it measures pulmonary pressures. A murmur can be heard with a stethoscope placed at the left lower sternal border. Cardiomegaly and ventricular hypertrophy are both demonstrated on electrocardiography and echocardiography.

Which statement explains why metabolic acidosis develops with kidney failure? 1. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2. Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4. Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Rationale: Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The client's urine output for the past 12 hours was 200 mL. The nurse notes a prescription for 900 mL of oral fluids over the next 24 hours. Which interpretation of the amount of prescribed fluid would the nurse make? 1. It equals the expected urinary output for the next 24 hours. 2. It will prevent the development of pneumonia and a high fever. 3. It will compensate for both insensible and expected output over the next 24 hours. 4. It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

It will compensate for both insensible and expected output over the next 24 hours. Rationale: Insensible losses are 500 mL to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

The nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart? supine dorsal recumbent left lateral recumbent sims

Left lateral recumbent position Rationale: The client should lie in the lateral recumbent position so that the nurse can effectively detect heart murmurs (as shown in Figure 2). The supine position provides easy access to the pulse sites (shown in Figure 1). The client should be placed in the dorsal recumbent position (Figure 3) for abdominal assessment. Sims position (Figure 4) is used so that the nurse can assess the rectum and vagina.

Which information would the nurse include in response to a client's questioning a protein-restricted dietary change required for his or her acute kidney injury? 1. "A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses." 2. "Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis." 3. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." 4. "Currently, your body is unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein."

"This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." Rationale: The amount of protein permitted in the diet depends on the extent of kidney function; excess protein causes an increase in urea concentration, excess metabolic waste, and added stress on the kidneys. The restricted protein diet prevents overburdening the client's kidneys at this time. When experiencing acute kidney injury, the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.

The nurse teaches a client with chronic kidney disease to avoid all salt substitutes in his or her diet. Which rationale supports the nurse's instruction? 1. A person's body tends to retain fluid when a salt substitute is included in the diet. 2. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood. 3. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. 4. The salt substitute substances interfere with capillary membrane transfer, resulting in anasarca.

Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. Rationale: Salt substitutes usually contain potassium, which can lead to hyperkalemia; dysrhythmias are associated with hyperkalemia. Chronic kidney disease already places the client at a higher risk for hyperkalemia because of poor elimination of fluids and electrolytes. Sodium, not salt substitutes, in the diet causes retention of fluid. Salt substitutes do not contain substances that influence blood urea nitrogen and creatinine levels; these are the result of protein metabolism. There is not a substance in the salt substitute that interferes with capillary membrane transfer. Anasarca is extensive fluid in the tissues throughout the body and more extensive than typical edema.

A child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5 ½ NS at 4 mL/h, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. Which is the priority nursing intervention? Auscultating breath sounds Testing the level of consciousness Measuring drainage from both tubes Determining the suction pressure of the nasogastric tube

Testing the level of consciousness Rationale: Assessing the level of consciousness provides the nurse with information about how awake the client is and therefore how able to clear the throat and protect the airway. The airway takes priority over listening to the lungs (checking for breathing: ABCs—airway-breathing-circulation), measuring drainage, or determining the suction pressure of the nasogastric tube.

Which medication prescribed for a client with an acute episode of heart failure would the nurse question? Diuretic Beta blocker Long-acting nitrate Angiotensin receptor blocker

Beta-blocker Rationale: Beta blockers reduce cardiac output and are contraindicated for clients with acute heart failure, although they are frequently used to prevent progression of chronic heart failure. Diuretics are used in acute heart failure to decrease hypervolemia and congestion. Long-acting nitrates are used in heart failure to reduce preload. Angiotensin receptor blockers are used in heart failure to decrease fluid overload and afterload.

A client with a history of chronic kidney disease is hospitalized. Which assessment findings would alert the nurse to suspect kidney insufficiency? 1. Facial flushing 2. Edema and pruritus 3. Dribbling after voiding 4. Diminished force of urination

Edema and pruritus Rationale: The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. Pallor, not flushing, occurs with chronic kidney disease as a result of anemia. Dribbling after voiding is a urinary pattern that is not caused by chronic kidney disease; this may occur with prostate problems. Diminished force and caliber of stream occur with an enlarged prostate, not kidney disease.

Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)? Flame burn Chemical burn Electrical burn Radiation burn

Electrical burn

A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect? First-degree burn Third-degree burn Fourth-degree burn Second-degree burn

First-degree burn

The primary health care provider for a client with chronic kidney disease prescribed immediate hemodialysis for the first time. Which clinical manifestation indicates the need for immediate hemodialysis in this client? 1. Ascites 2. Acidosis 3. Hypertension 4. Hyperkalemia

Hyperkalemia Rationale: Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sounds on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. One, some, or all responses may be correct. Providing oxygen immediately Notifying the rapid response team Considering it a normal observation Initiating an intravenous (IV) line and beginning fluid replacement Obtaining an electrocardiogram (ECG) of the client

Providing oxygen immediately Notifying the rapid response team

Which nursing intervention is the priority when the nurse notices that the client has a blood pressure of 90/70 mm Hg and a heart rate of 50 beats per minute while the nurse is performing nasotracheal suctioning? Administer intravenous fluids to the client. Report to the primary health care provider. Stop the suctioning procedure immediately. Administer 100% oxygen manually to the client.

Stop the suctioning procedure immediately. Rationale: Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. A blood pressure of 90/70 mm Hg and heart rate of 50 breaths per minute indicate hypotension and bradycardia so the nurse would immediately stop the suctioning procedure. The nurse can report to the primary health care provider, but only after stopping the suctioning. The nurse can administer intravenous fluids to the client, but only after ensuring the safety of the client. The nurse can administer 100% oxygen to the client, but only after stopping suctioning.

A client who is experiencing diplopia, ptosis, and mild dysphagia is newly diagnosed with myasthenia gravis. Which instruction would the nurse include when planning care with the client and spouse? Restrict the diet to liquids and foods that are pureed. Perform range-of-motion exercises. Remember to use a stool softener daily. Take prescribed anticholinergic medications on schedule.

Take prescribed anticholinergic medications on schedule.

When the nurse is obtaining the health history for a client with mitral valve stenosis, which question will be most relevant to ask? "Do you frequently get urinary tract infections?" "Have you had a recent episode of pneumonia?" "Did you ever have strep throat during childhood?" "Do you have a family history of heart attack or angina?"

"Did you ever have strep throat during childhood?" Rationale: Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve.

Which change in the client's lab results indicates that the client is in septic shock? 1) Blood glucose of 80 mg/dL 2) An increased serum lactate level 3) An increased neutrophil level 4) A white blood count (WBC) of 5000 cells/µL

2) An increased serum lactate level

A client with a 10-year history of emphysema is hospitalized for acute respiratory distress. Which assessment finding would the nurse expect to identify? 1) Chest pain on inspiration 2) Prolonged expiration with use of accessory muscles 3) Signs and symptoms of respiratory alkalosis 4) Decreased respiratory rate

2) Prolonged expiration with use of accessory muscles

A client is admitted to an intensive care unit with a diagnosis of acute respiratory distress syndrome (ARDS). The nurse expects which assessment finding? 1) Hypertension 2) Tenacious sputum 3) Altered mental status 4) Slow rate of breathing

3) Altered mental status

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include? 1) They are indicative of pleural rubbing. 2) They are signs of bronchial constriction. 3) Crackles are located in the smaller air passages. 4) Crackles are heard during respiratory expiration.

3) Crackles are located in the smaller air passages.

A client has burn injuries from an electrical current. Which interventions would be used as first aid until the client is transferred to a health care facility? Select all that apply. One, some, or all responses may be correct. Cover the burns with ice. Leave the adherent clothing in place. Wrap the client in a dry, clean sheet. Remove as much burned clothing as possible. Immerse the burned body part in cool water.

Leave the adherent clothing in place. Wrap the client in a dry, clean sheet. Remove as much burned clothing as possible.

Which landmark is correct for the nurse to use when auscultating the mitral valve? Left fifth intercostal space, midaxillary line Left fifth intercostal space, midclavicular line Left second intercostal space, sternal border Left fifth intercostal space, sternal border

Left fifth intercostal space, midclavicular line

Which findings would support a client's diagnosis of Parkinson disease? SATA Nonintentional tremors Frequent bouts of diarrhea Masklike facial expression Hyperextension of the neck Rigidity to passive movement

Nonintentional tremors Masklike facial expression Rigidity to passive movement

A client is scheduled to have a Tensilon test. Which response to the test would confirm the diagnosis of myasthenia gravis? Brief exaggeration of symptoms Prolonged symptomatic improvement Rapid but brief symptomatic improvement Symptomatic improvement of only the ptosis

Rapid but brief symptomatic improvement

Which activity would the nurse teach clients to avoid after having implantation of a permanent cardiac pacemaker? Having a computed tomography (CT) scan Standing near a microwave Swimming in saltwater Touring a power plant

Touring a power plant Rationale: Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.

When assessing a client who has aortic stenosis and is scheduled for aortic valve replacement, which finding by the nurse is most important to communicate to the health care provider? Loud systolic murmur Multiple dental caries Heartburn when lying down Paroxysmal nocturnal dyspnea

multiple dental caries Rationale: Multiple dental caries increase the risk for endocarditis in clients with valvular disease and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors, but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? SATA 1) Tachycardia 2) Restlessness 3) Warm, moist skin 4) Decreased urinary output 5) Bradypnea

1) Tachycardia 2) Restlessness 4) Decreased urinary output

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? 1) Implanted port 2) Midline catheter 3) 18-gauge peripheral venous catheter 4) Peripherally inserted central catheter (PICC) line

4) Peripherally inserted central catheter (PICC) line

Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1) Chest tube insertion 2) Aggressive diuretic therapy 3) Administration of beta-blockers 4) Positive end-expiratory pressure (PEEP)

4) Positive end-expiratory pressure (PEEP)

Pyridostigmine bromide is prescribed for a client with myasthenia gravis. The nurse evaluates that the medication regimen is understood when the client makes which statement? "I will take the medication on an empty stomach." "I need to set an alarm so I take the medication on time." "It will be important to check my heart rate before taking the medication." "I should monitor for an increase in blood pressure after taking the medication."

"I need to set an alarm so I take the medication on time."

An arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client is most likely to exhibit these blood gas results? 1) A client with pulmonary fibrosis 2) A client with uncontrolled type 1 diabetes 3) A client who has been vomiting for 3 days 4) A client who takes sodium bicarbonate for indigestion

1) A client with pulmonary fibrosis

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1) Encouraging a fluid intake of 3 L daily 2) Suctioning via the tracheostomy every hour 3) Applying an occlusive dressing over the surgical site 4) Using cotton balls to cleanse the stoma with peroxide

1) Encouraging a fluid intake of 3 L daily

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance would the nurse identify based on these results? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

1) Metabolic acidosis

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. The nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%

22.5%

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1) Administer sedatives as frequently as possible. 2) Turn the client every 4 hours. 3) Increase ventilator settings every 2 hours. 4) Suction as needed.

4) Suction as needed.

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? 1) Hypoxemia 2) Hypocapnia 3) Compensated metabolic acidosis 4) Uncompensated respiratory acidosis

4) Uncompensated respiratory acidosis

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? SATA 1) Spasticity 2) Incontinence 3) Flaccid paralysis 4) Respiratory failure 5) Lack of reflexes below the injury

3) Flaccid paralysis 5) Lack of reflexes below the injury

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 beats/minute to 121 beats/minute? 1) Septic shock 2) Cardiogenic shock 3) Hemorrhagic shock 4) Neurogenic shock

3) Hemorrhagic shock

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? 1) Decreased rate of glomerular filtration 2) Excessive blood loss through the burned tissues 3) Plasma proteins moving out of the intravascular compartment 4) Sodium retention occurring as a result of the aldosterone mechanism

3) Plasma proteins moving out of the intravascular compartment

Which nursing intervention is specific to clients in active labor who present with a history of cardiac disease? Encouraging frequent voiding Checking the blood pressure hourly Auscultating the lungs for crackles every 30 minutes Helping turn the client from side to side at 15-minute intervals

Auscultating the lungs for crackles every 30 minutes Rationale: Clients with cardiac problems are prone to heart failure during active labor; crackles indicate the presence of pulmonary edema. Encouraging frequent voiding and checking the blood pressure hourly is done for all clients who are in labor. Helping turn the client from side to side at 15-minute intervals is not necessary; although clients who are in labor are maintained on the side to facilitate venous return, the sides do not have to be alternated every 15 minutes.

The wound characteristics of four different clients with burns are mentioned below. Which client mostlikely suffers skin injury from sunburn? Client 1 - pink-red, mild edema, pain, no blisters, no eschar, 3-6d healing Client 2 - red-white, moderate edema, pain, blisters rare, no eschar, 2w healing time Client 3 - black-brown, severe edema, no pain, no blisters, hard and inelastic eshcar, weeks-months healing time Client 4 - black, no edema, no pain, no blisters, hard and inelastic eschar, weeks to months healing time

Client 1 - pink-red, mild edema, pain, no blisters, no eschar, 3-6d healing

The nurse reviews the kidney function blood studies of four clients. Which client's results indicate kidney impairment? Client 1: Serum Creatinine 0.1 mg/dL; BUN 16 mg/dL Client 2: Serum Creatinine 0.8 mg/dL; BUN 18 mg/dL Client 3: Serum Creatinine 1.2 mg/dL; BUN 20 mg/dL Client 4: Serum Creatinine 1.9; BUN 22 mg/dL

Client 4 Rationale: Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys. If the kidneys are not able to remove urea from the blood normally, the blood urea nitrogen (BUN) level rises. The normal range of serum creatinine lies between 0.6 and 1.2 mg/dL (53.04-106.08 mmol/L). The normal range of BUN lies between 10 and 20 mg/dL (3.57-7.14 mmol/L). Client 4's levels indicate kidney impairment. The serum creatinine and BUN are within normal limits for clients 1, 2, and 3.

The nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery would the nurse report to the primary health care provider immediately? Small amount of yellowish-green oozing Moderate area of serosanguineous oozing Epithelialization under the nonadherent dressing Separation of the edges of the nonadherent dressing

Small amount of yellowish-green oozing

A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client? Encourage bed rest for this client. Space activities throughout the day. Teach the limitations imposed by the disease. Have one of the client's relatives stay at the bedside.

Space activities throughout the day.