NU372 Final Exam Prep

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction will the nurse give the client regarding nutrition? a) "Eat more dark green, leafy vegetables such as spinach." b) "Substitute a potassium-based salt substitute for table salt." c) "Return to previous eating habits." d) "Increase intake of dairy products."

a) "Eat more dark green, leafy vegetables such as spinach." - The client should increase the dietary intake of potassium because of potassium loss associated with chlorothiazide. Leafy green vegetables are high in potassium and should be encouraged. Salt substitutes should only be used if prescribed by the provider; otherwise, they should be discouraged because electrolyte abnormalities may occur without close monitoring. Returning to previous eating habits may be unsafe for those who do not consume a nutritional diet; the client should be taught about medication-induced deficiencies and how to try to prevent future TIAs. Dairy products should be limited, unless fat-free, because they are high in saturated fats.

The nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. One, some, or all responses may be correct. a) "Wear a large-brimmed hat." b) "Take your temperature daily." c) "Balance periods of rest and activity." d) "Use a strong soap when washing the skin." e) "Expose the skin to the sun as often as possible."

a) "Wear a large-brimmed hat." b) "Take your temperature daily." c) "Balance periods of rest and activity." - A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? a) "Wear cotton underwear or lingerie." b) "Void at least every 6 hours around the clock." c) "Increase foods containing alkaline ash in the diet." d) "Wipe the perineum from back to front after toileting."

a) "Wear cotton underwear or lingerie." - Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments. Voiding frequently helps flush ascending microorganisms from the bladder, thereby reducing the risk for urinary tract infections; holding urine for more than 6 hours can lead to urinary tract infections. Foods high in acid, not alkaline ash, help acidify urine; this urine is less likely to support bacterial growth. Alkaline urine promotes bacterial growth. Wiping the genitals from back to front after toileting may transfer bacteria from the perianal area toward the urinary meatus, which will increase the risk for urinary tract infection.

Which causative agent is common to both hyperthermia and hypothermia? a) Alcohol b) Barbiturates c) Phenothiazines d) Cardiovascular disease

a) Alcohol - Alcohol is the causative agent that is common to both hyperthermia and hypothermia. Barbiturates and phenothiazines can cause hypothermia. Cardiovascular disease can cause hyperthermia.

When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct. a) Anxiety b) caffeine c) exercise d) anemia e) hypothermia

a) Anxiety b) caffeine c) exercise d) anemia - Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants (such as caffeine), fever, and sympathetic response to fear or pain (for example, anxiety). Hypothermia will cause sinus bradycardia.

A client with which diagnosis will be at risk for development of a pulmonary embolism? a) Atrial fibrillation b) Forearm laceration c) Migraine headache d) Respiratory infection

a) Atrial fibrillation - Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headache. Respiratory infections do not increase pulmonary embolism risk.

Which characteristic of urine changes in the presence of a urinary tract infection (UTI)? a) Clarity b) Viscosity c) Glucose level d) Specific gravity

a) Clarity - Cloudy urine usually indicates drainage associated with infection. Viscosity is a characteristic that is not measurable in urine. Urinary glucose levels are not affected by UTIs. Specific gravity yields information related to fluid balance.

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

a) Cold, clammy skin - In cardiogenic shock, the action of the sympathetic nervous system causes vasoconstriction, which causes the skin to be cold and clammy. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs. Because of poor cardiac contractility, pulse quality is weak. Blood pressure decreases because of poor cardiac output. Hypoperfusion leads to hypoactive or absent bowel sounds.

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media? a) Complete the entire course of antibiotic therapy. b) Herbal fever remedies are highly discouraged. c) Administer the medication with meals. d) Stop the antibiotic therapy when the child no longer has a fever.

a) Complete the entire course of antibiotic therapy. - Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the health care provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse would not discourage use of herbal fever remedies; however, the herbal treatment would be reviewed to see if it is contraindicated. Ampicillin would be taken 1 to 2 hours after meals. Antibiotic therapy would be completed as prescribed.

The nurse is preparing to administer a vaccine to a child. Which conditions, if present, would allow for the safe administration of the vaccine? Select all that apply. One, some, or all responses may be correct. a) Current antimicrobial therapy b) Mild to moderate local reactions c) Anaphylactic reaction to vaccines d) Recent exposure to infectious diseases e) Moderate to severe illness with or without fever

a) Current antimicrobial therapy b) Mild to moderate local reactions d) Recent exposure to infectious diseases - A vaccine can be safely administered even if the child is on any antimicrobial therapy or develops a mild to moderate local reaction. Recent exposure to an infectious disease is not a contraindication. A vaccine is contraindicated if the child has moderate to severe illness with or without fever or develops an anaphylactic reaction.

A client with rheumatoid arthritis has been taking a corticosteroid medication for the past year. Prolonged use of corticosteroids puts this client at increased risk for which complication? a) Decreased white blood cells b) Increased C-reactive protein c) Increased sedimentation rate d) Decreased serum glucose levels

a) Decreased white blood cells - Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. C-reactive protein and sedimentation rate are elevated in acute inflammatory diseases; steroids help decrease them. Serum glucose levels increase with steroid use.

While awaiting surgery, a client with a history of Crohn disease is receiving total parenteral nutrition (TPN) on an outpatient basis. The nurse teaches the client that TPN helps prepare for surgery by which process? a) Decreasing fecal bulk b) Preventing bowel infection c) Providing stimulation of secretions d) Maintaining negative nitrogen balance

a) Decreasing fecal bulk - By decreasing fecal bulk and bowel stimulation, TPN provides rest for the bowel while the client awaits surgery. TPN does not prevent a bowel infection. TPN does not stimulate gastrointestinal secretions. TPN promotes positive nitrogen balance.

The nurse is providing colostomy care to a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? Select all that apply. One, some, or all responses may be correct. a) Gloves b) gown c) mask d) goggles e) shoe covers f) hair bonnet

a) Gloves b) gown d) goggles - Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. A mask would be necessary if the client had MRSA of the nares. Shoe covers and hair bonnet are not required for the client care situation described.

A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant? a) Heparin b) Warfarin c) Clopidogrel d) Enoxaparin

a) Heparin - Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and of prothrombin to thrombin. Warfarin, a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2 to 3 months. Clopidogrel is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. A low-molecular-weight heparin (e.g., enoxaparin) is not administered during the acute stage; it may be administered later to prevent future deep vein thromboses.

A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestations would the nurse assess in the client? Select all that apply. One, some, or all responses may be correct. a) Jaundice b) Acute pain c) Hypertension d) Hypoglycemia e) Increased amylase

a) Jaundice b) Acute pain e) Increased amylase - Obstruction of the common bile duct by inflammation leads to jaundice. Autodigestion of the pancreas causes severe abdominal pain. Obstruction of the pancreatic duct leads to elevated levels of amylase and lipase. Hypotension, not hypertension, is caused by fluid shifting out of the intravascular space. Decreased pancreatic function causes hyperglycemia, not hypoglycemia.

Which clinic manifestations would the nurse expect to find in a client who has acute human immunodeficiency virus (HIV) infection? Select all that apply. One, some, or all responses may be correct. a) Malaise b) Confusion c) Constipation d) Swollen lymph glands e) Oropharyngeal candidiasis

a) Malaise d) Swollen lymph glands - Soon after being infected with HIV, many clients develop a flu-like syndrome called acute HIV infection. Clinical manifestations of this syndrome include malaise, swollen lymph glands, fever, sore throat, headache, nausea, diarrhea, muscle or joint pain, or a diffuse rash. Confusion is associated with later stages of HIV infection when clients may develop acquired immunodeficiency syndrome (AIDS)-dementia complex or an opportunistic infection that affects the neurologic system. Diarrhea, not constipation, is associated with acute HIV infection. Oropharyngeal candidiasis occurs during later stages of HIV infection, when clients show symptoms of poor immune function.

Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? a) Oropharyngeal candidiasis b) Cryptosporidiosis c) Toxoplasmosis encephalitis d) Pneumocystis jiroveci pneumonia

a) Oropharyngeal candidiasis - Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is more common in a client infected with acquired immunodeficiency syndrome (AIDS). It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? a) Oxygen saturation: 89% b) Body temperature: 101°F c) Blood pressure: 130/80 mm Hg d) Respiratory rate: 26 beats/minute

a) Oxygen saturation: 89% - An oxygen saturation of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

When the nurse needs to determine atrial rate and rhythm, which component of the electrocardiogram will be used? a) P waves b) PR intervals c) T waves d) QRS complexes

a) P waves - The P wave represents atrial depolarization and the nurse would use P waves to determine atrial rate and rhythm. The PR interval represents the time it takes for an impulse to completely depolarize the atria and the atrioventricular node and would not be used to assess atrial regularity. T waves represent ventricular repolarization and are not used to assess atrial or ventricular regularity. QRS complexes represent ventricular depolarization and would be used to determine ventricular regularity and heart rate.

When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next? a) Perform a head-to-toe assessment. b) Place the client on restricted fluid intake. c) Discuss a restricted sodium diet with the client. d) Document the findings in the health care record.

a) Perform a head-to-toe assessment. - Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular distention with right-sided heart failure, or pulmonary crackles associated with left-sided heart failure. More assessment data is needed before deciding whether fluid restrictions are needed for this client. Restricting sodium in the diet is appropriate for most clients with heart failure, but assessment for symptoms of worsening heart failure is a higher priority. Documentation of findings is needed, but not as important as assessing the client for symptoms that may indicate a need for changes in the therapeutic plan.

When caring for a client with peripheral arterial insufficiency, how would the nurse position the client's feet and legs? a) Place them slightly lower than the head and chest. b) Use pillows to support the heels above the mattress. c) Raise the knees using the knee gatch on the bed. d) Elevate feet by raising the foot of the bed on blocks.

a) Place them slightly lower than the head and chest. - Gravity will assist the flow of blood to the dependent legs and feet (placed lower than the head and chest). Elevating the heels on pillows will decrease blood flow to the feet. Bending the knees with the use of the knee gatch will decrease blood flow to the feet. Elevating the foot of the bed will decrease blood flow to the feet.

Which topics would be included when teaching a client with heart failure who will be discharged with a new prescription for digoxin? Select all that apply. One, some, or all responses may be correct. a) Take your radial pulse daily and write it down. b) Avoid foods that are high in potassium such as bananas and potatoes. c) Notify the health care provider if you develop any vision changes. d) Call the health care provider if your pulse is irregular or less than 60 beats/minute. e) Eat at least 1 serving of green leafy vegetables daily.

a) Take your radial pulse daily and write it down. c) Notify the health care provider if you develop any vision changes. d) Call the health care provider if your pulse is irregular or less than 60 beats/minute. - Clients taking digoxin should be taught how to take a radial pulse and to document pulse rate and bring results to all medical appointments. Hypokalemia may increase the risk for digoxin toxicity, and clients are advised to eat high-potassium foods such as bananas and potatoes. Vision changes may indicate digoxin toxicity and should be reported to the health care provider. Pulse irregularity or a rate less than 60 beats/minute may indicate digoxin toxicity, and clients should report these changes to the health care provider. Green leafy vegetables contain large quantities of vitamin K, but this does not affect digoxin at all.

In clients with human immunodeficiency virus (HIV), which potential complication is most important for the nurse to teach prevention strategies? a) infection b) depression c) social isolation d) kaposi sarcoma

a) infection - The client has a weakened immune response. Instructions regarding rest, nutrition, and avoidance of unnecessary exposure to people with infections help reduce the risk for infection. Clients can be taught cognitive strategies to cope with depression, but the strategies will not prevent depression. The client may experience social isolation as a result of society's fears and misconceptions; these are beyond the client's control. Although Kaposi sarcoma is related to HIV infection, there are no specific measures to prevent its occurrence.

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result? a) "The result indicates that you have active tuberculosis." b) "The result indicates that you are infected with the tuberculosis organism." c) "The result indicates that there are no tuberculin antibodies in your system." d) "The result indicates that you have a secondary infection related to the tuberculin organism."

b) "The result indicates that you are infected with the tuberculosis organism." - An indurated area 5 mm or larger noted 48 to 72 hours after the tuberculin test indicates that the person is infected with the tuberculin organism. A positive tuberculin skin test accompanied by fever, coughing, weakness, and positive chest x-ray are manifestations of active tuberculosis. The other choices are incorrect.

A client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." Which is the best action for the nurse to take? a) Educate the client about the complications associated with high blood pressure. b) Ask the client questions to determine the current understanding of high blood pressure. c) Emphasize the importance of taking blood pressure medications now to continue to feel well. d) Show the client the current blood pressure and compare that with normal blood pressure levels.

b) Ask the client questions to determine the current understanding of high blood pressure. - Further assessment of the client's understanding of hypertension and treatment is important before the nurse can develop an effective plan to change the client's behavior. Education about complications of hypertension may be helpful, but first the nurse needs to know what the client already understands about the long-term effects of high blood pressure. An emphasis on taking medications now to ensure future health may be appropriate for this client, but further assessment is needed before using this strategy. Many clients may respond to actually seeing the difference between their blood pressures and the expected normals, but more information about the client's knowledge is needed to know if this will be a useful strategy for this client.

A client arrives for an influenza vaccination and reports a low-grade fever with a cough. Which action would the nurse take next? a) Administer aspirin with the vaccine. b) Check the temperature and current history. c) Hold the vaccine and notify the health care provider. d) Reschedule administration of the vaccine for the next month.

b) Check the temperature and current history. - Vaccines may be administered during a mild febrile illness and upper respiratory infection, so the nurse would assess further. Administering aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary. Vaccinations should not be delayed unless the illness is moderate to severe.

When caring for a client with pneumonia, which nursing intervention is the highest priority? a) Increase fluid intake. b) Employ breathing exercises and controlled coughing. c) Ambulate as much as possible. d) Maintain a nothing-by-mouth (NPO) status.

b) Employ breathing exercises and controlled coughing. - For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? a) Giving influenza vaccine to the client b) Having suction available during meals c) Assisting the client to take deep breaths d) Teaching about incentive spirometer use

b) Having suction available during meals - Because a client with difficulty swallowing is at risk for aspiration, having suction available will be the most effective intervention in preventing aspiration pneumonia. Giving the influenza vaccine is important in preventing viral pneumonia, but would not help prevent aspiration. Deep breathing is important to prevent atelectasis, but would not prevent aspiration pneumonia. Incentive spirometer use is important in preventing atelectasis, but not helpful in preventing aspiration.

Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints? a) Urate crystals in the synovial tissue b) Inflammation in the joint's synovial lining c) Formation of bony spurs on the joint surfaces d) Deterioration and loss of articular cartilage joints

b) Inflammation in the joint's synovial lining - In rheumatoid arthritis, transformed autoantibodies attack synovium, producing inflammation. Urate crystals occur with gouty, not rheumatoid, arthritis. Formation of bony spurs on the joint surfaces is unrelated to rheumatoid arthritis. Deterioration and loss of articular cartilage in joints is osteoarthritis.

When a client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions, which action by the nurse will be most helpful? a) Administer continuous oxygen. b) Offer fluids at frequent intervals. c) Place the client in a high-Fowler position. d) Administer prescribed steroid inhaler.

b) Offer fluids at frequent intervals. - Increased fluid intake helps liquefy respiratory secretions, which promotes expectoration. The client may need oxygen administration, but the airways must be cleared before oxygen can effectively reach the alveoli. Placing the client in a high Fowler position will help increase lung expansion, but will not improve cough effort or make secretions easier to expectorate. Steroid inhalers may decrease airway inflammation, but will not help make respiratory secretions easier to expectorate.

A primary health care provider diagnoses the client's condition as otitis media. Which assessment finding supports that diagnosis? a) Nodules on the pinna b) Redness of the eardrum c) Lesions in the external canal d) Excessive cerumen in the external canal

b) Redness of the eardrum - Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity, but not the manifestation of otitis media. Excessive soft cerumen in the external canal affects the hearing acuity, but not the manifestation of otitis media.

When a staff nurse is instructed by the charge nurse to give the scheduled warfarin dose to a client whose current international normalized ratio (INR) is 6, which action would the staff nurse take first? a) Refuse to give the unsafe medication dose. b) Remind the charge nurse of the INR result. c) Ask the hospital pharmacist to talk with the nurse manager. d) Ask the health care provider whether to give the medication.

b) Remind the charge nurse of the INR result. - Because the INR is at an unsafe level, the warfarin would not be given. Professional communication would include first clarifying concerns with the charge nurse, by discussing the abnormal INR result and reasons for not administering another dose of warfarin. Although the nurse could refuse to give the medication as the first action, this is not likely to foster professional communication or workplace relationships. Direct communication with coworkers about concerns is more professional and fosters better relationships than having a third party (such as the pharmacist) address concerns. Because the INR is prolonged and the warfarin would be unsafe to give, the nurse does not need to ask the health care provider about giving the warfarin, but would notify the provider about the INR result.

Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. a) Multiple mosquito bites b) Sharing syringe needles c) Breast-feeding a newborn d) Dry kissing an infected individual e) Anal intercourse f) Sharing drinking glasses

b) Sharing syringe needles c) Breast-feeding a newborn e) Anal intercourse - Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites, sharing of drinking glasses, or dry kissing. Deep kissing involving a large amount of salvia does transmit HIV.

The nurse identifies 12 mm of induration at the site of a client's tuberculin purified protein derivative (PPD) test. Which rational would the nurse use to explain this test? a) The test result is negative and would not require any follow-up. b) The result indicates a need for further tests and a chest x-ray. c) The skin test is a screening method and you now need a Tine test. d) This skin test is inconclusive and requires repeat testing in 6 weeks.

b) The result indicates a need for further tests and a chest x-ray. - The tuberculin PPD is injected intradermally; it is the most accurate skin test for tuberculosis (TB) because of the testing material and the intradermal method used. No other skin test is appropriate as a follow-up; further tests are now warranted, including a chest x-ray film. The test result is positive, not negative; thus further testing is necessary. The Tine test is less accurate than the tuberculin PPD and is not used as a follow-up test. More than 10 mm of induration is a positive test result, not a doubtful test result.

Intravenous furosemide has been prescribed for a client with severe edema and hypertension. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply. One, some, or all responses may be correct. a) Hunger b) Tinnitus c) Weakness d) Leg cramps e) Excess salivation

b) Tinnitus c) Weakness d) Leg cramps - Tinnitus is a central nervous system side effect of furosemide. Weakness and leg cramps result from hypokalemia caused by an overload of furosemide. Nausea and anorexia, not hunger, are side effects of dehydration that may occur with an overload of furosemide. Dry mouth, not salivation, results from dehydration caused by an overload of furosemide.

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. a) Weight loss b) Unusual fatigue c) Dependent edema d) Nocturnal dyspnea e) Increased urinary output

b) Unusual fatigue c) Dependent edema d) Nocturnal dyspnea - 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. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.

Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. One, some, or all responses may be correct. a) diarrhea b) anorexia c) weight gain d) hemoptysis e) night sweats

b) anorexia d) hemoptysis e) night sweats - Tuberculosis is an infectious respiratory disease caused by Mycobacterium tuberculosis. Signs include a persistent cough, anorexia, hemoptysis, night sweats, shortness of breath, and a high body temperature. Diarrhea and weight gain are not associated with tuberculosis.

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? a) surgery b) comfort c) education d) motivation

b) comfort - Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.

Which nursing intervention would prevent stimulation of the pancreas in a client with acute pancreatitis? a) Maintain the gastric pH at a level of less than 3.5. b) Encourage the resumption of activities of daily living. c) Administer the histamine H2-receptor antagonist as prescribed. d) Ensure that the nasogastric tube remains in the fundus of the stomach.

c) Administer the histamine H2-receptor antagonist as prescribed. - The histamine H2-receptor antagonist medication inhibits histamine at H2-receptor sites in parietal cells, thus decreasing gastric secretion and preventing pancreatic stimulation. A lower pH will stimulate pancreatic secretion, which contains bicarbonate ions that neutralize the acid. The client should rest to decrease stimulation of the pancreas. The tube should be positioned nearer the pylorus for the removal of gastric contents.

Which laboratory test would the nurse review for a client suspected to have rheumatoid arthritis? a) Pancreatic lipase b) Bence Jones protein c) Antinuclear antibody d) Alkaline phosphatase

c) Antinuclear antibody - An antinuclear antibody test may be positive in clients with autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. Pancreatic lipase is an enzyme that catalyzes the breakdown of lipids; this is a test used to diagnose pancreatic problems. Bence Jones protein is a urine test helpful in diagnosing multiple myeloma. Alkaline phosphatase is a blood test that determines phosphorus activity; it is used in diagnosing liver and biliary tract disorders and identifying periods of active bone growth or metastasis of cancer to bone.

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

c) Client report of feeling very thirsty - With hypovolemic shock, extravascular fluid depletion leads to client feeling of thirst. With hypovolemia, urine output will decrease due to compensatory mechanisms designed to retain volume. Elevated temperature might occur with septic shock, but temperature may be lower with hypovolemia because of poor perfusion. With hypovolemia, pulses would be weak.

Which intervention would the nurse perform to prevent disease transmission when caring for a hospitalized client with influenza? a) Dispose of all sharps. b) Administer antibiotics. c) Don a mask in the room. d) Wear a disposable gown.

c) Don a mask in the room. - The way to prevent the transmission of influenza is by instituting droplet precautions. The care involved is to wear a mask when in the client's room. Disposing of all sharps prevents the transmission of bloodborne diseases. Antibiotics are not effective against viral infections such as influenza. Gowns are used when preventing transmission of contaminated body fluids such as stool or urine.

Which nursing action will be most helpful in preventing transmission of influenza in crowded communities? a) Teaching correct hand-washing techniques b) Demonstrating how to cover the mouth when coughing c) Educating about the importance of having annual vaccinations d) Giving antiviral medications within 48 hours of symptom development

c) Educating about the importance of having annual vaccinations - Immunization is the most effective way to prevent communicable diseases. Hand washing will be helpful in decreasing person-to-person spread of influenza, but not as effective as preventing influenza through immunization. Covering the mouth when coughing helps decrease respiratory droplet spread, but is not as effective as immunization in preventing influenza transmission. Antiviral medications such as oseltamivir need to be started within 48 hours after symptoms develop and will shorten the course of the infection, but do not decrease transmission as effectively as immunization.

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. For which potential life-threatening complication would the nurse assess the client postoperatively? a) Wound infection b) Ischemia of the stoma c) Fluid deficit and electrolyte imbalance d) Excoriation of skin around the stoma

c) Fluid deficit and electrolyte imbalance - An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist indicating adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication.

When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? a) Chest x-ray b) Thoracic ultrasound c) Helical computed tomography (CT) d) Magnetic resonance imaging (MRI)

c) Helical computed tomography (CT) - Helical CT is the most commonly used test to detect pulmonary embolism. Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool. Thoracic ultrasound might be used for pleural effusion, but not to diagnose pulmonary embolism. MRI testing is not used for diagnosis of pulmonary embolism.

Which medication will the nurse question when it is prescribed for a client with acute pancreatitis? a) Ranitidine b) Cimetidine c) Meperidine d) Promethazine

c) Meperidine - Meperidine should be avoided because accumulation of its metabolites can cause central nervous system irritability and even tonic-clonic seizures (grand mal seizures). Ranitidine is useful in reducing gastric acid stimulation of pancreatic enzymes. Cimetidine is useful in reducing gastric acid stimulation of pancreatic enzymes. Promethazine is useful as an antiemetic for clients with pancreatitis.

When a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment, which action would the nurse take next? a) Teach the client about the need for a low sodium diet. b) Ask the client when blood pressure medications were taken last. c) Question the client about symptoms such as headache or chest pain. d) Call for an ambulance to transport the client to the emergency department.

c) Question the client about symptoms such as headache or chest pain. - The nurse's initial action would be to determine if the client is having symptoms that might indicate acute complications such as stroke or acute coronary syndrome. The client may need teaching about dietary sodium reduction, but more assessment is needed before the nurse implements teaching. Failure to take blood pressure medications is a common reason that clients have sudden increases in blood pressure, but it is more important to determine if the client is having complications caused by the elevated blood pressure. If the client is having symptoms of stroke or acute coronary syndrome, an ambulance would be called for transport to the hospital, but an elevated blood pressure alone is not an indicator of a need for emergency services.

Which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men? a) Inadequate fluid intake b) Poor hygienic practices c) The length of the urethra d) The disruption of mucous membranes

c) The length of the urethra - The length of the urethra is shorter in women than in men; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in women also increases the incidence of urinary tract infections. Fluid intake may or may not be adequate in both men and women and does not account for the difference. Hygienic practices can be inadequate in men or women. Mucous membranes are continuous in both men and women.

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? a) Proteinemia b) Contractures c) Tissue ischemia d) Thrombus formation

c) Tissue ischemia - Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first. Proteinemia and contractures are not complications resulting from long-term edema. Although thrombus formation may occur, the initial assessment is perfusion (tissue ischemia).

A client recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary health care provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests would the nurse expect the primary health care provider to prescribe to confirm this diagnosis? a) Cystoscopy and bilirubin level b) Specific gravity and pH of the urine c) Urinalysis with a urine culture and sensitivity d) Creatinine clearance and albumin/globulin (A/G) ratio

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

Which statement by an adolescent during an annual physical examination indicates the need for human immunodeficiency virus (HIV) testing? a) "I only have sex with one partner." b) "I always use barrier contraception." c) "I occasionally smoke pot with friends." d) "I have shared needles when using drugs."

d) "I have shared needles when using drugs." - Risk factors for HIV infection include sharing intravenous drug needles. Therefore, this statement indicates a need for HIV testing. Monogamous sex, use of barrier contraception, and smoking pot are not high-risk behaviors.

Which statement by the nursing student indicates understanding of the precautions needed in the provision of care to a child who is human immunodeficiency virus (HIV) positive? a) "I'll put on a mask." b) "I'll put on an N-95 mask." c) "I'll put on a gown and gloves." d) "I'll put on gloves if I'm going to be in contact with body fluids."

d) "I'll put on gloves if I'm going to be in contact with body fluids." - The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) recommends standard precautions for the care of individuals with HIV infection or acquired immune deficiency syndrome (AIDS) without opportunistic infections. Droplet precautions are not necessary because HIV is not transmitted in large-particle respiratory droplets. Contact precautions are not necessary unless the HIV infection or AIDS is complicated by the presence of disease or infection, necessitating the addition of these precautions to standard precautions. Airborne precautions are unnecessary because HIV is not spread in airborne droplet nuclei; these precautions are used in addition to standard precautions if an opportunistic infection such as Mycobacterium tuberculosis is present.

A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best? a) "This is an unfortunate situation, but there was such a limited supply available." b) "There are many others who were unable to obtain a flu vaccine this month." c) "The limited supply doesn't really matter because the vaccine is for one particular strain." d) "There are other things you and your family can do to prevent the flu, such as hand washing."

d) "There are other things you and your family can do to prevent the flu, such as hand washing." - The statement "There are other things you can do to prevent the flu, such as hand washing" is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response "It's unfortunate, but there was such a limited supply available" is empathic, but it does not address the client's concern of vulnerability. The response "There are many others who also were unable to get a flu vaccine" belittles the client for being concerned. The response "It doesn't matter because the vaccine is for just one particular strain" may be true, but it belittles the client's concern.

For which complication is a client with gestational hypertension at risk? a) Placenta previa b) Polyhydramnios c) Isoimmunization d) Abruptio placentae

d) Abruptio placentae - Vasospasms of placental vessels occur because of increased blood pressure. As a result, the placenta may separate prematurely (abruptio placentae). Placenta previa is an abnormal placental implantation and is not related to hypertension. Polyhydramnios, an excessive amount of amniotic fluid, is not associated with hypertensive disorders of pregnancy. Isoimmunization in pregnancy is associated with Rh incompatibility, not hypertension.

Famotidine is prescribed for a client with peptic ulcer disease. Which mechanism of action is a characteristic of this medication? a) Increases gastric motility b) Neutralizes gastric acidity c) Facilitates histamine release d) Inhibits gastric acid secretion

d) Inhibits gastric acid secretion - Famotidine decreases gastric secretion by inhibiting histamine at H2 receptors. Increasing gastric motility, neutralizing gastric acidity, and facilitating histamine release are not actions of famotidine.

The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? a) Inclusion of transmural involvement of the small bowel wall b) Higher occurrence of fistulas and abscesses from changes in the bowel wall c) Pathology beginning proximally with intermittent plaques found along the colon d) Involvement starting distally with rectal bleeding that spreads continuously up the colon

d) Involvement starting distally with rectal bleeding that spreads continuously up the colon - Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client? a) Private room b) Semiprivate room c) Room with windows that can be opened d) Negative-airflow room

d) Negative-airflow room - Tuberculosis is an airborne contagious disease that is best contained in a negative-airflow room. Negative-airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

Which activity places a client at risk for hyperthermia? a) Snowmobiling b) Skiing in the winter c) Hiking Alaskan mountains d) Performing strenuous activity in high humidity

d) Performing strenuous activity in high humidity - When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. Activities such as snowmobiling, skiing, and hiking in cold weather may cause hypothermia because they occur in cold temperatures and may lower the body temperature.

A client with human immunodeficiency virus (HIV) reports dyspnea on exertion, increased heart rate, a persistent dry cough, and a persistent low-grade fever. The nurse auscultates bilateral crackles in the lower lung lobes. Which organism would the nurse suspect is responsible for this condition? a) Cryptosporidium b) Candida albicans c) Toxoplasma gondii d) Pneumocystis jiroveci

d) Pneumocystis jiroveci - Pneumocystis jiroveci causes pneumonia, which is the most common opportunistic infection in clients infected with the human immunodeficiency virus (HIV). Symptoms of Pneumocystis jiroveci pneumonia include dyspnea on exertion, tachypnea, a persistent dry cough, and a persistent low-grade fever. An auscultation of the breath sounds indicates crackles. Cryptosporidium causes diarrhea and weight loss. Candida albicans causes mouth pain and difficulty swallowing. Toxoplasma gondii causes speech and vision difficulty.

The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? a) P wave b) T wave c) PR interval d) QRS complex

d) QRS complex - The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. Normally a P wave indicates that the sinoatrial node initiated the impulse that depolarized the atrium. The T wave represents ventricular repolarization. The interval from the beginning of the P wave to the next deflection from the baseline is called the PR interval and represents depolarization of the sinoatrial node, both atria, and the atrioventricular node.

The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? a) Respirations of 10 b) Urine output of 30 mL/hour c) Lethargy d) Restlessness

d) Restlessness - In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.

Which suggestion would the nurse make to a client with rheumatoid arthritis who asks about ways to decrease morning stiffness? a) Wear loose but warm clothing. b) Plan a short rest break periodically. c) Avoid excessive physical stress and fatigue. d) Take a hot bath or shower in the morning.

d) Take a hot bath or shower in the morning. - Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness. Although wearing loose but warm clothing is advisable for someone with arthritis, it does not relieve morning stiffness. Inactivity promotes stiffness. The practice of avoiding excessive physical stress and fatigue is related to muscle fatigue, not to stiffness of joints.

Which factor would the nurse consider when the parent of a 10-month-old infant expresses frustration that this is the baby's third otitis media in 3 months? a) Analgesics are contraindicated. b) Oral antibiotics will be prescribed. c) The labyrinth and cochlea are inflamed. d) The eustachian tube is short and horizontal.

d) The eustachian tube is short and horizontal. - This anatomical difference in young children permits easier migration of microorganisms from the oral cavity into the middle ear, predisposing them to otitis media. Analgesics such as acetaminophen or ibuprofen are recommended to relieve discomfort. Studies have shown that antibiotics are not always necessary in children over 6 months old without severe symptoms. Antibiotic therapy is necessary when the infant has a fever or is in severe pain. The labyrinth and cochlea are part of the inner ear and are not affected by otitis media.

Which finding is indicative of hypothermia in a newborn? Select all that apply. One, some, or all responses may be correct. a) Seizures b) Diaphoresis c) Flushed skin d) Poor feeding e) Hypoglycemia

e) Hypoglycemia - Hypoglycemia in a newborn can indicate hypothermia or cold stress. Seizures, diaphoresis, flushed skin, and poor feeding are indicative of hyperthermia.