NUR 411 practice exam 3

Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? A. Anticoagulants B. Antihypertensives C. Antidysrhythmics D. Antibiotics

A A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots. Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.

Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax? A. Distended neck veins B. Mediastinal shift toward the left side C. Right-sided pain on deep inhalation D. Right side of the chest more prominent than the left

A Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.

A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? A. respiratory assessment B. cardiovascular assessment C. abdominal assessment D. pain assessment

A As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS).

The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A. blood glucose B. BUN C. phosphorus D. platelet count

A During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment.

Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg? A. Collaborating with the pulmonary health care provider to lower the FiO2 level B. Assessing cognition C. Placing the client in the prone position D. Preparing to suction the client

A Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation.Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? A. Hemoptysis and shortness of breath B. Fever and tracheal deviation C. Audible wheezing on inhalation and exhalation D. Paradoxical chest movements

A Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear? A. Suctioning the tracheostomy tube B. Remove the inner cannula of the tracheostomy C. Humidifying the oxygen source D. Increasing the percentage of oxygen

A The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure.Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. "These interventions help to reduce the ammonia level." B. "These interventions help to prevent heart failure." C. "These interventions help the client's jaundice improve." D. "These interventions help to prevent nausea and vomiting."

A The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder? A. Assessing the client at least hourly for tachypnea and dyspnea B. Performing meticulous mouth during mechanical ventilation C. Assessing for abnormal lung sounds D. Monitoring urine output to identify multiple organ dysfunction syndrome early

A The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen.Abnormal lung sounds are not present at this stage because the edema is present in the interstitial tissues and not in the airways. At this stage, clients are neither intubated nor being mechanically ventilated. Multiple organ dysfunction syndrome is not a feature of this stage.

What type of acid-base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29? A. Respiratory acidosis with an acid excess B. Metabolic acidosis with an acid excess C. Respiratory acidosis with a base deficit D. Metabolic acidosis with a base deficit

A When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.

What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax? A. Dull B. Hyperresonant C. Crackling D. Hypertympanic

A With a hemothorax, percussion on the involved side produces a dull sound because the blood in the lung area prevents air from filling the area. Lung crackling sounds cannot be percussed, although skin crackling with subcutaneous emphysema can. Tympanic sounds on percussion are associated with abdominal assessment, not pulmonary. Any degree of resonance is associated with air-filled lung areas, not blood-filled areas. INCORRECT

The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? Select all that apply. A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen E. Sodium F. Protein

A, B, C, D Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver.

The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

A, B, C, D, E Clients having this complex surgery can develop any or all of the postoperative complications listed in the test item.

The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin F. Calcium

A, B, C, D, E The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium.

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? Select all that apply. A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia

A, B, C, D, E, F Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.

A client is admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this client? Select all that apply. A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting D. Decreased serum amylase level E. Leukocytosis F. Dyspnea

A, B, C, E, F Clients who have acute pancreatitis usually have an elevated serum amylase level, not a decreased level. Therefore, Choice D is an incorrect response. All of the other choices are typical signs and symptoms of acute pancreatitis

When caring for a client with portal hypertension, the nurse assesses for which potential complications? Select all that apply. A. Esophageal varices B. Ascites C. Hematuria D. Hemorrhoids E. Fever

A, B, D Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

Which clients will the nurse monitor most closely for respiratory failure? (Select all that apply.) A. A 30 year old with a C-5 spinal cord injury B. A 55 year old with a brainstem tumor C. A 50 year old experiencing cocaine intoxication D. A 65 year old with COVID-19 pneumonia E. A 35 year old using client-controlled analgesia F. A 40 year old with acute pancreatitis

A, B, D, E, F Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness.Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) A. Inspiratory chest pain B. Dizziness and syncope C. Pink, frothy sputum D. Worsening dyspnea for 3 days E. Tachycardia F. Productive cough

A, B, E Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply. A. Dyspnea B. Electrocardiograph shows ST elevation C. Intercostal retractions D. PaO2 84% on oxygen at 6 L/minute E. Substernal pain or rubbing F. Wheezing on exhalation

A, C, D The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus, wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.

The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A. Decreased ascitic fluid B. Changes in consciousness or behavior C. Fatigue and weakness D. Decreased pulse rate

B Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak.

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? A. Assessing gums daily for indications of bleeding B. Monitoring the platelet count daily C. Assessing breath sounds D. Comparing pedal pulses bilaterally

B Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.

With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? A. A 50 year old with type 2 diabetes mellitus and cellulitis of the leg B. A 36 year old who had open reduction and internal fixation of the tibia C. A 25 year old receiving IV antibiotics through a peripheral line D. A 72 year old with dehydration and hypokalemia taking oral potassium supplements

B Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Assist the client to assume a position of comfort. B. Administer opioid analgesic medication. C. Do not administer food or fluids by mouth. D. Measure intake and output every shift.

B Pain relief is the highest priority for the client with acute pancreatitis. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority

In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)? A. Registered dietitian nutritionist B. Respiratory therapist C. Occupational therapist (OT) D. Pharmacist

B The client with a PE has ongoing respiratory problems that change gas exchange almost hourly and require adjustments in respiratory support. The respiratory therapist will be collaborating with the nurse and client at least daily. Other team members listed have roles than change with the client's condition and collaboration is more intermittent.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 60 year old who was recently extubated and reports a sore throat. B. A 50 year old being mechanically ventilated who has tracheal deviation. C. A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing. D. A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.

B The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.

A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and having a reddish-purple, nonitchy rash on her chest. After assessing the client, what is the nurse's best action or response to prevent harm?' A. Ask the client about possible drug allergies B. Apply oxygen and call the rapid response team C. Determine when she last received an opioid dose D. Check the oxygen saturation and encourage her to cough

B This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.

For which problems will the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds? (Select all that apply.) A. Mucous plugs are in the endotracheal tube. B. Leak in the ventilator tubing circuit. C. Client is not breathing. D. Cuff leak in the endotracheal or tracheostomy tube. E. Ventilator tubing is under the client. F. Client is attempting to breathe against the ventilator

B, C, D Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the "support" mode, and when a leak is present in the ventilator tubing circuit.Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or "bucking" the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure.

When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? Select all that apply. A. Elevated magnesium B. Swollen abdomen C. Prolonged partial thromboplastin time D. Elevated amylase level E. Currant jelly stool F. Icterus of skin

B, C, F Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) A. Ensure that drainage color is clear. B. Check blood glucose often. C. Place the client in the supine position. D. Check bowel sounds and stools. E. Monitor mental status.

B, D, E To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

What is the nurse's best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%? A. Documenting the finding in the electronic health record as the only action B. Initiating the Rapid Response Team C. Removing the endotracheal tube and ventilating the client with a bag-valve-mask D. Obtaining a different monitor and rechecking the end-tidal carbon dioxide level

C A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client's throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client's life. The nurse will perform these actions while having another health care worker call the Rapid Response Team.If the client's SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.

A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A. Cirrhosis B. Crohn Disease C. Peritonitis D. Peptic Ulcer Disease

C Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage.

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths? A. Assist-control (AC) ventilation B. Continuous positive airway pressure (CPAP) C. Synchronized intermittent ventilation (SIMV) D. Bi-level positive airway pressure (BiPAP)

C Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient's own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client.BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client's own respiratory rate increases, which could lead to over-ventilation.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? A. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%. B. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs. C. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia. D. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain.

C The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.

The client is a 5 foot 11 inch tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are: pH= 7.32; PaO2 = 84 mm Hg; PaCO2 = 56 mm Hg. What is the nurse's interpretation of these results? A. Ventilation adequate to maintain oxygenation. B. Ventilation excessive; respiratory alkalosis present. C. Ventilation inadequate; respiratory acidosis present. D. Ventilation status cannot be determined from information presented.

C The average-size adult female has a normal tidal volume of 400-500 mL. However this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.

Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Monitoring serum albumin levels B. Lowering the head of the bed C. Administering oxygen therapy D. Administering intravenous fluids

C The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath.Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. deep vein thrombosis. B. jaundice. C. hematemesis. D. pressure injury.

C The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition

C The client's assessment does not indicate the presence of anxiety or malnutrition. Therefore, Choices A and D are incorrect responses. The client is at a risk for dehydration due to vomiting, but the actual client problem of acute pain (Choice C) is a higher priority than a potential problem that does not exist at the present time for a young adult (Choice B)

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. D. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography.

C The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? A. Partial bronchial airway obstruction B. Thickened alveolar membranes and poor gas exchange C. Increased oxygen need resulting from a septic clot PE D. Shunting of deoxygenated blood to the left side of the heart

D A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.

The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A. Increased blood pressure B. Decreased weight C. Increased pulse D. Decreased pain

D A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. A 22 year old with a fractured clavicle B. A 39 year old with uncontrolled diabetes C. A 56 year old with chronic kidney disease D. A 74 year old who aspirates a tube feeding

D ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration.Fractured clavicle, diabetes, and chronic kidney disease is associated with an increased risk for lung injury or ARDS.

Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? A. Increasing temperature B. Abdominal cramping C. Hand tremors D. Distended neck veins in the high-Fowler position

D Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Calcium B. Potassium C. Magnesium D. Sodium

D Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? A. "I need to take the enzymes at every meal and with snacks." B. "After taking the enzymes, I should drink a glass of water." C. "I should wipe my mouth in case any of the enzyme got on my lips." D. "I should chew each capsule carefully so that it works in my stomach."

D Pancreatic enzymes should not be chewed because they can irritate the mouth and they need to be released slowly. Therefore, Choice D is an incorrect statement and indicates a need for further teaching by the nurse. The other statements are correct about how to take pancreatic enzyme replacements.

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax? A. Left chest caves in on inspiration and "puffs out" on expiration. B. The left lung field is dull to percussion and crackles are present on auscultation. C. The client has bloody sputum and wheezes. D. Chest is asymmetrical and trachea deviates toward the right side.

D Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest has paradoxical chest movement with a "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers? A. Administering the prescribed sedating drug B. Explaining to the client that the tube helps with breathing C. Requesting that the family leave to decrease the client's agitation D. Assessing for adequate oxygenation

D The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client's anxiety.

The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Acute kidney injury B. Hypertension C. Pulmonary edema D. Infection

D The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

How would the home care nurse best modify the client's home environment to manage side effects of lactulose? A. Obtains a walker for the client. B. Rearranges furniture to declutter the home. C. Removes throw rugs to prevent falls. D. Requests a bedside commode for the client.

D The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

Which action will the nurse instruct a client with an endotracheal tube to perform during the time the tube is being removed? A. Hold his or her breath B. Inhale C. Cough D. Exhale

D The nurse instructs the client to inhale deeply right before extubation while the nurse deflates the tube cuff. The tube is removed while the client exhales. The nurse instructs the client to cough immediately after extubation.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Fat B. Fiber C. Carbs D. Protein

D The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.

Which action will the nurse take first while caring for a client being mechanically ventilation when the high-pressure alarm sounds? A. Comparing the ventilator settings with the prescribed settings B. Turning off the alarm then assess the need for suctioning C. Notifying the respiratory therapist D. Auscultating the client's breath sounds

D The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse's priority assessment during client care? A. Cardiovascular assessment B. Abdominal assessment, including bowel sounds C. Respiratory assessment D. Cognitive and neurologic assessment

D The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium

In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? A. Administering sodium bicarbonate B. Having the client breathe rapidly and deeply into a paper bag C. Assessing for the presence of adventitious lung sounds D. Increasing the oxygen flow rate

D These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe hypoxemia (low PaO2) from greatly reduced gas exchange. This client needs more oxygen now.by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority