post-assessment b
A nurse is teaching a client who has a family history of hemophilia A about manifestations of the disorder. The nurse should include which of the following manifestations in the teaching? a. frequent rapid bleeding b. tendency to bruise minimally c. immediate clotting from a minor cut d. disabling joint pain
d. disabling joint pain A client who has hemophilia A can have disabling joint pain over time, especially of the knee and hip, because of hemorrhage into the joints.
A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses? a. malignant melanoma b. basal cell carcinoma c. squamous cell carcinoma d. Kaposi's sarcoma
a. malignant melanoma These findings are consistent with malignant melanoma, which is associated with changes in preexisting nevi.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? a. vitamin B12 injections b. iron supplements c. blood transfusions d. vitamin B6 supplements
a. vitamin B12 injections The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption.
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? a. finger b. earlobe c. toe d.skin fold
b. earlobe The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.
A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication? a. sleepy, but arouses when name is called b. respiratory rate 8/minute c. pain level of 6 on scale from 0 to 10 d. SaO2 94%
b. respiratory rate 8/minute A respiratory rate of 8/min represents an adverse effect of the morphine and the nurse should notify the provider. Expected respiratory rate is 12/min or greater.
A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? a. extremities that turned blue when exposed to cold b. tingling feeling in the extremities c. jerking movements of the extremities d. spasms of the extremities
b. tingling feeling in the extremities Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator=associated pneumonia? a. position head of client's bead in the flat position b. turn the client every 4 hr c. brush the client's teeth with a suction toothbrush every 12 hr d. provide humidity by maintaining moisture within the ventilator tubing
c. brush the client's teeth with a suction toothbrush every 12 hr The nurse should brush the client's teeth every 12 hr and rinse the client's mouth with an antimicrobial rinse to reduce the growth of bacteria.
A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor? a. elevated WBC b. fever c. ecchymosis d. fatigue
c. ecchymosis A client who as ITP has a decreased number of circulating platelets, which are important for blood clotting. One of the first manifestations seen in clients who have an exacerbation of ITP is the development of bruises (ecchymoses) and petechiae. The greatest risk to this client is bleeding. Therefore, the nurse's priority is to monitor for occult bleeding and the development of ecchymosis.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? a. clamp the chest tube prior to transferring the client to a wheelchair b. disconnect the chest tube from the drainage system during transport c. keep the drainage system below the level of the client's chest at all times d. empty the collection chamber prior to transport
c. keep the drainage system below the level of the client's chest at all times During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.
A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? a. apply ice to the burns b. place the child in a tub of cool water c. pour tepid water over the burns d. cover the burns with a blanket
c. pour tepid water over the burns Tepid water reduces pain and swelling and conducts the heat of the burns away from the skin.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24hr following a burn injury? a. D5W b. D5NS c. NS d. Lactated Ringer's
d. Lactated Ringer's Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? a. aplastic anemia is associated with a decreased intake of iron b. aplastic anemia results in an increased rate of RBC destruction c. aplastic anemia results in an inability to absorb vitamin B12 d. aplastic anemia results from decreased bone marrow production of RBCs
d. aplastic anemia results from decreased bone marrow production of RBCs Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow.
A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client? a. exhale slowly b. turn head to the right c. sit in semi-Fowler's position d. bear down while holding breath
d. bear down while holding breath The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation.
A nurse assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for ... a. side effects of immunosuppressants b. constipation c. fatigue d. bleeding
d. bleeding Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding. In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client.
A nurse is teaching a client who has stomatitis. Which of the following instructions should the nurse include? a. rinse with a commercial mouthwash b. use toothpaste that contains sodium laurel sulfate c. cleanse the mouth with lemon-glycerin swabs d. brush teeth with a soft toothbrush
d. brush teeth with a soft toothbrush The client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? a. check tubing connections for leaks b. check the suction control outlet on the wall c. clamp the chest tube d. continue to monitor the client's respiratory status
d. continue to monitor the client's respiratory status Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.
A nurse is preparing to start an IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hours. How many mL/hr should the nurse set the pump to infuse for the first 8 hours? (Round to nearest whole number)
325 mL/hr The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL. This amount should then be divided by the first 8 hours.
A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I will have to stay in bed for several hours after the procedure b. I will turn my head in the opposite direction during insertion c. I will need to hold my breath when they first put the needle in d. I will call the clinic if I have persistent hiccups
b. I will turn my head in the opposite direction during insertion The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? a. pertussis b. mycoplasma pneumonia c. tuberculosis d. respiratory syncytial virus
c. tuberculosis Tuberculosis is transmitted by small droplets. Therefore, nurses providing care to clients who have tuberculosis should wear individually fitted N95 respirator masks.
While caring for a client, the nurse experiences a needlestick injury. Which of the following actions should the nurse take first? a. complete an incident report b. request the risk manager obtain consent for HIV testing from the client c. wash the site of injury with soap and water d. consent to postexposure treatment with antiretroviral meds
c. wash the site of injury with soap and water The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.
A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be ... a. infertility b. diarrhea c. dyspnea d. dysphagia
d. dysphagia Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness.
A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? a. WBC 2300/mm3 b. RBC 5 million/mm3 c. hemoglobin 12 g/dl d. platelets 155000/mm3
a. WBC 2300/mm3 This WBC finding is below the expected reference range. Chemotherapy treatment can cause leukopenia; the nurse should report this finding to the provider and implement precautions to protect the client from infection.
A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. WHich of the following statements should the nurse make? a. You should avoid drinking liquids an hour before the treatments b. Eating low-calorie foods helps prevent nausea c. Foods that are higher in fat are usually more appealing d. Raw fruits and vegetables will be easier for your body to digest
a. You should avoid drinking liquids an hour before the treatments Clients should be encouraged to decrease fluid intake just before treatments because fluids may cause nausea and vomiting.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? a. a room with air exhaust directly to the outdoor environment b. a room with another nonsurgical client c. a room in the ICU d. a room that is within view of the nurses' station
a. a room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? a. administer a SABA b. obtain a peak flow reading c. administer an inhaled glucocorticoid d. determine the cause of the acute exacerbation
a. administer a SABA When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take? a. administer each unit over 3 hr b. use an 18 gauge needle to obtain venous access c. use blood that is less than a month old d. obtain the client's vital signs every 30 min throughout the transfusion
a. administer each unit over 3 hr The nurse should administer blood to an older adult client at a slower rate. Therefore, each unit should be administered over 2 to 4 hr.
A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? a. administer high-flow oxygen at 5 L/min by facemask to the client b. place the client in high-Fowler's position with legs dependent c. give the client sublingual nitroglycerin d. reassure the client
a. administer high-flow oxygen at 5 L/min by facemask to the client A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen at 5 L/min by facemask to the client.
A nurse in the emergency department is caring for a client who has extensive partial + full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? a. airway obstruction b. infection c. fluid imbalance d. paralytic ileus
a. airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan? a. apply pressure to needlestick sites for 10 min b. assess core temperatures using a rectal thermometer c. measure abdominal girth twice weekly d. monitor for the presence of WBCs in the urin
a. apply pressure to needlestick sites for 10 min A client who has thrombocytopenia has a decreased number of platelets. The nurse should apply pressure to needlestick sites for a minimum of 10 min because of the client's decreased clotting ability.
A nurse is assessing an older client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (SATA) a. bounding pulse b. pitting edema c. swelling at the IV site d. urine-specific gravity > 1.030 e. crackles upon auscultation
a. bounding pulse b. pitting edema e. crackles upon auscultation Fluid volume excess is due to excessive fluid intake or inadequate fluid excretion. Manifestations include increased blood pressure, pulse, and respirations. With fluid volume excess, the pulse is full and bounding. Excess extracellular fluid can lead to pitting edema in dependent areas of the body. Pulmonary edema can occur with fluid volume excess.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? a. check the results of the client's most recent CBC b. assess the client for a hypersensitivity reaction c. evaluate the client for hypercalcemia d. examine the client for hepatomegaly
a. check the results of the client's most recent CBC The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher.
A nurse is caring for a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should the nurse include in the discussion? (SATA) a. cryosurgery b. electrosurgery c. radiation therapy d. topical corticosteroids e. micrographic surgery
a. cryosurgery b. electrosurgery c. radiation therapy e. micrographic surgery Cryosurgery freezes cancerous tissue and is used in the treatment of BCC. Electrosurgery uses electrical energy to destroy and remove cancerous tissue and is used in the treatment of BCC Depending on client's age and the location of the tumor, radiation therapy is used in the treatment of BCC. Mohs micrographic surgery is used in the treatment of BCC and is the most accurate method of removing a tumor while preserving healthy tissue
A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? a. irregular borders b. purulent drainage c. uniform pigmentation d. intense pruritus
a. irregular borders Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter.
A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic lab values should the nurse expect? (SATA) a. decreased platelet count b. increased hemoglobin count c. decreased leukocyte count d. increased platelet count e. decreased erythrocyte count
a. decreased platelet count c. decreased leukocyte count e. decreased erythrocyte count The nurse should expect to see a decreased platelet count due to bone marrow suppression from the chemotherapy treatment. The nurse should expect to see a decreased leukocyte count due to bone marrow suppression from the chemotherapy treatment. The nurse should expect to see a decreased erythrocyte count due to bone marrow suppression from the chemotherapy treatment.
When assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? a. discontinue the existing IV line b. initiate a new IV line in the other extremity c. apply a hot pack to the irritated site d. determine if the client needs to continue IV therapy
a. discontinue the existing IV line The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? a. do not apply heat to the area of irradiation b. do not wash the area of irradiation c. use an antibiotic ointment to treat skin breakdown d. lubricate the skin with hypoallergenic lotion
a. do not apply heat to the area of irradiation This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation.
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (SATA) a. dyspnea b. bradycardia c. barrel chest d. clubbing of the fingers e. deep respirations
a. dyspnea c. barrel chest d. clubbing of the fingers Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? a. eating a high fiber diet will reduce my risk for developing skin cancer b. I should check my skin monthly for any changes c. I should avoid the use of tanning booths d. I should use sunscreen even on cloudy days
a. eating a high fiber diet will reduce my risk for developing skin cancer A high-fiber diet is recommended to reduce the risk for COLON cancer.
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? a. excessive thrombosis and bleeding b. progressive increase in platelet production c. immediate sodium and fluid retention d. increased clotting factors
a. excessive thrombosis and bleeding The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways.
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a. fatigue b. hypertension c. bradycardia d. diarrhea
a. fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs.
A nurse is reviewing the lab results of a client who has acute radiation syndrome and notes the client has leukopenia. Which of the following assessment findings should the nurse identify as being consistent with leukocytosis? a. fever b. bruising c. pallor d. petechiae
a. fever Acute radiation syndrome results in a decrease in many of the blood cell types including lymphocytes, leukocytes, thrombocytes, and red blood cells. A fever would be an expected finding of a decreased number of white blood cells (leukopenia).
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? a. generalized urticaria b. blood pressure 184/92 mmHg c. distended jugular veins d. bilateral flank pain
a. generalized urticaria The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm.
A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? a. headache b. dependent edema c. polyuria d. photosensitivity
a. headache Headache is a common adverse effect of ondansetron. Analgesic relief is often required.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (SATA) a. increased heart rate b. increased BP c. increased respiratory rate d. increased hematocrit e. increased temperature
a. increased heart rate b. increased BP c. increased respiratory rate The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a. large incisions will be made in the eschar to improve circulation b. this procedure involves placing the client into a shower and removing the dead tissue c. a piece of healthy skin will be removed from an unburned area and grafted over the burned area d. dead tissue will be non-surgically removed
a. large incisions will be made in the eschar to improve circulation An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? a. measure circumference of both upper arms b. notify provider who inserted the PICC line c. remove the PICC line d. apply a cold pack to the client's upper arm
a. measure circumference of both upper arms The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.
A nurse is caring for a client who has the following arterial blood results: HCO3 18 mEq, PaCO2 28 mmHg, and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? a. metabolic acidosis b. respiratory acidosis c. metabolic acidosis d. respiratory alkalosis
a. metabolic acidosis a client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3, and a decreased PaCO2
A nurse is caring for a client 4 hr postop following a kidney biopsy. Which of the following interventions should the nurse take? (SATA) a. monitor for hematuria b. check for flank pain c. monitor for extravasation of tissue surrounding biopsy site d. encourage ambulation e. administer aspirin prn for pain
a. monitor for hematuria b. check for flank pain Monitoring for hematuria is appropriate following a kidney biopsy to assist in detecting bleeding Checking for flank pain is appropriate following a kidney biopsy to assist in detecting bleeding
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? a. movement of the trachea toward the unaffected side b. bubbling of the water in the water seal chamber with exhalation c. crepitus in the area above and surrounding the insertion site d. eyelets are not visible
a. movement of the trachea toward the unaffected side A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? a. recombinant b. packed RBCs c. prophylactic antibiotics d. fresh frozen plasma
a. recombinant The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.
A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? a. refusing to look at the dressing or surgical incision b. asking for pain meds q3hr c. asking questions about the info on her postoperative care pamphlet d. performing arm exercises once or twice a day
a. refusing to look at the dressing or surgical incision Clients who refuse to look at the surgical incision or surgical dressing are having difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client is not yet ready to acknowledge the results of the surgery.
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis
a. respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9000/mm3. The nurse should monitor the client for which of the following conditions? a. spontaneous bleeding b. oliguria c. hyperactive deep tendon reflexes d. infection
a. spontaneous bleeding The nurse should consider the risk of spontaneous bleeding that can occur in clients who have low platelets. Low platelet levels cause clotting time to increase.
A nurse is caring for a client who is 1 day postop following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (SATA) a. squeezing a rolled washcloth b. flexing and extending the hand c. flexing and extending the elbow d. rotation of the shoulder e. hand wall climbing
a. squeezing a rolled washcloth b. flexing and extending the hand c. flexing and extending the elbow During the first 24 hr following a mastectomy, the client should perform exercises that do not stress the incision, such as squeezing a rolled washcloth or a soft ball, flexing and extending the hand, and flexing and extending the elbow
A nurse is assessing a client who is receiving one unit of packed RBCs to treata intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mmHg. Which of the following actions should the nurse take first? a. stop the infusion of blood b. inform the provider c. obtain a urin specimen d. notify the laboratory
a. stop the infusion of blood This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? a. suction two to three times with a 60 second pause between passes b. perform chest physiotherapy prior to suctioning c. lubricate the suction catheter tip with sterile saline d. hyperventilate the client on 100% oxygen prior to suctioning
a. suction two to three times with a 60 second pause between passes Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.
A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? a. these organs support immunity b. these organs are used in digestion c. these organs regulate electrolyte balance d. these organs assist vitamin absorption
a. these organs support immunity The nurse should inform the client that the function of the thymus, spleen, and lymph nodes is to support immunity and fight infection.
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated and alone in this room." After acknowledging the client's feelings of loneliness, which of the following responses should the nurse provide? a. I will come and sit with you for 10 minutes each hour b. Do you have a cell phone you can talk to your friends and family on? c. I'll ask the charge nurse to admit someone to your room for company d. You're scheduled for discharge in 2 days so this isolation will be over soon
b. Do you have a cell phone you can talk to your friends and family on? A client who has a radiation implant must remain in radiation isolation. Time and distance are the factors that reduce exposure to the source. After acknowledging the client's feelings of loneliness and recognizing the sense of social isolation, this solution provides an appropriate, safe means of meeting the client's need for contact.
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings? a. a multi-colored lesion with irregular borders b. a small, translucent papule with rolled borders c. a crusted lesion with indurated margins d. a small macule with dry yellow scale
b. a small, translucent papule with rolled borders This finding is consistent with basal cell carcinoma.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. give morphine IV b. administer oxygen therapy c. start an IV infusion of Lactated Ringer's d. initiate cardiac monitoring
b. administer oxygen therapy The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smoked. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mmHg. Her ABGs are pH 7.50, PaCO2 29 mmHg, PaO2 60 mmHg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? a. prepare for mechanical ventilation b. administer oxygen via face mask c. prepare to administer a sedative d. assess for indications of pulmonary embolism
b. administer oxygen via face mask The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? a. eat plenty of fresh fruits and vegetables b. avoid crowds c. perform mild exercise, such as gardening d. take temperature weekly
b. avoid crowds The nurse should inform the client to avoid crowds due to his suppressed immune system.
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? a. constant bubbling in the suction-control chamber b. continuous bubbling in the water-seal chamber c. bloody drainage in the collection chamber d. fluid-level fluctuations in the water-seal chamber
b. continuous bubbling in the water-seal chamber Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client's chest. However, gentle bubbling on forceful exhalation or coughing is normal.
A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? a. blistering b. erythema c. eschar d. absence of pain
b. erythema Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.
A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements should the nurse include in the teaching? a. most clients do not experience nausea b. hair loss is common and includes eyebrows and eyelashes c. most clients start to gain weight during their treatment d. clients lose their hair but it usually grows back nice and thick
b. hair loss is common and includes eyebrows and eyelashes This nursing statement is correct, because alopecia occurs as a whole-body hair loss for most clients administered chemotherapy.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? a. BP b. heart rate c. urine output d. weight
b. heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? a. insert an indwelling urinary catheter b. inspect the mouth for signs of inhalation injuries c. administer intravenous pain medication d. draw blood for a complete blood cell (CBC) count
b. inspect the mouth for signs of inhalation injuries Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.
A nurse is reviewing the PT, aPTT, and INR lab values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following lab results should the nurse expect? a. lab values WNL b. lab values prolonged c. lab values decreased d. lab values same as previous test values
b. lab values prolonged These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? a. Kussmaul respirations b. apneustic respirations c. Cheyne-Stokes respirations d. stridor
c. Cheyne-Stokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).
A nurse is assessing the IV catheter insertion site for a client receiving D5 1/2 NS at 75 cc/hr and noticed swelling at the site with decreased skin temperature. Which of the following actions should the nurse take? (SATA) a. obtain a specimen for culture at the insertion site b. start a new IV access distal to this site c. elevate the client's arm d. apply warm compresses to the insertion site e. stop the infusion
c. elevate the client's arm d. apply warm compresses to the insertion site e. stop the infusion Elevate the arm of a client who is experiencing edema with an infiltration Apply a warm or cold compress for a client who is experiencing manifestations of an IV infiltration, depending on the solution. Decreased temperature and swelling at the insertion site are manifestations of IV infiltration. Stop the infusion and start a new line in the other extremity.
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? a. metabolic alkalosis b. hypervolemia c. hyperkalemia d. low hemoglobin
c. hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and ocntact the provider immediately? a. serosanguineous drainage from the puncture site b. discomfort at the puncture site c. increased heart rate d. decreased temperature
c. increased heart rate Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? a. age of the client b. associated medical history c. location of burn d. cause of the burn
c. location of burn When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress.
A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? a. blockage of the ET tube by the client's tongue b. passage of the ET tube into the esophagus c. movement of the ET tube into the right main bronchus d. infection of the vocal cords
c. movement of the ET tube into the right main bronchus During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube.
A client is receiving treatment for stage IV ovarian caner and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? a. good b. guarded c. poor d. very good
c. poor At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? a. maintaining a semi-Fowler's position as often as possible b. administering oxygen via nasal cannula at 2 L/min c. helping client select low-salt diet d. encourage client to drink 2-3 L of water daily
d. encourage client to drink 2-3 L of water daily COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.
A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make? a. provide the client with articles from the internet that explain colon cancer stages b. assure the client that the provider will explain what has been planned c. explain the various options available for treatment based on the cancer stage d. encourage the client to write down questions to ask the provider
d. encourage the client to write down questions to ask the provider The nurse does not know the answers to the client's questions, so helping the client to prepare questions for the provider addresses the client's needs.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? a. febrile b. allergic c. acute pain d. hemolytic
d. hemolytic A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse.
A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification? a. chart b. order sheet c. medication administration record d. identification wristband
d. identification wristband This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? a. obtain a cardiology consult b. suction the client less frequently c. administer an antidysrhythmic medication d. perform pre-oxygenation prior to suctioning
d. perform pre-oxygenation prior to suctioning Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
A nurse is caring for a client who has active pulmonary tuberculosis and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? a. constipation b. black-colored stools c. staining of teeth d. red-colored urine
d. red-colored urine Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
A nurse is providing teaching to a client who has a superficial lesion and has had a biopsy that indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice? a. cryosurgery b. chemotherapy c. radiation therapy d. surgical excision
d. surgical excision Surgical excision is the treatment of choice for superficial lesions of malignant melanoma.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mmHg Base excess -2 PaO2 78 mmHg Saturation 80% Bicarbonate 26 mEq/L
respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).
