Practice Questions I've missed

Which instructions would the nurse include when teaching a client with multiple sclerosis about managing urinary retention? Select all that apply. a. Using the Credé maneuver b. Using an indwelling catheter c. Using anticholinergic medications d. Monitoring and restricting fluid intake to 800 mL daily e. Monitoring and reporting signs of urinary tract infection

a. Using the Credé maneuver e. Monitoring and reporting signs of urinary tract infection Rationale: The Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with MS. Early recognition and treatment of infection are important to decrease the risk of exacerbation in the client with MS. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties, as concentrated urine increases the risk of urinary tract infection.

After the nurse provides discharge teaching for a client who had a femoropopliteal bypass graft, which client action indicates that the teaching has been effective? a. Walking for 10 minutes twice a day b. Elevating the legs when sitting or lying c. Taking a hot bath before going to bed d. Discontinuing prescribed daily aspirin

a. Walking for 10 minutes twice a day Rationale: After surgery for peripheral arterial disease, clients are instructed to start taking short walks and to gradually increase frequency and distance. Elevation of the legs would decrease arterial blood flow through the graft; leg elevation is recommended for venous disease. Clients with peripheral artery disease should avoid extremes of hot or cold, because these can injure extremities with poor perfusion. Continuing use of antiplatelet medications such as aspirin is needed to prevent arterial thrombus in blood vessels with poor perfusion.

Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? a. Genetic valvular heart disease b. Atherosclerotic plaques within arteries c. Developmental defects in arterial walls d. Emboli ascending from the lower extremities

b. Atherosclerotic plaques within arteries Rationale: Atherosclerotic plaques within arteries progressively narrow the lumens of the carotid arteries, causing TIAs. Valvular defects usually cause cerebral emboli that result in a brain attack. Brain aneurysms are developmental defects that may rupture, resulting in a brain attack. Emboli arising from the lower extremities usually result in occlusions in the pulmonary vascular system, causing a pulmonary embolus.

When a client has venous insufficiency, which finding by the nurse will be of most concern? a. Bilateral brown lower leg discoloration b. Calf pain when the feet are dorsiflexed c. Severe edema from ankles to calves d. Thickened and dry skin on lower legs

b. Calf pain when the feet are dorsiflexed Rationale: Calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptom of possible venous thrombosis and would require further diagnostic testing and treatment. Bilateral brown lower leg discoloration is a common symptom of chronic edema caused by venous insufficiency and would be expected in this client. Severe edema is a common and expected symptom of venous insufficiency and may require actions such as leg elevation, but is not as concerning as a positive Homans sign. Thick and dry skin is common in chronic venous insufficiency and the nurse will plan to use lubricating ointment, but is not as big a concern as a possible venous thrombosis.

A client is receiving mechanical ventilation. When condensation collects in the ventilator tubing, which action would the nurse take? a. Notify a respiratory therapist b. Drain the fluid from the tubing c. Decrease the amount of humidity d. Record the amount of fluid removed from the tubing

b. Drain the fluid from the tubing Rationale: Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid, and others have to be temporarily disconnected while the fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Humidity is necessary to preserve moistness of the respiratory tract and to help liquefy secretions. The amount of condensation is irrelevant when recording total intake and output.

Which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia

b. Dyspnea Rationale: FES is clinically manifested by dyspnea because of low levels of arterial oxygen. Nausea and orthopnea are not seen in FES. However, tachypnea, headache, and lethargy are seen in clients with FES. Paresthesia occurs with compartment syndrome.

After the nurse has presented a staff education session on the use of adenosine for supraventricular tachycardia, which statement by a staff member indicates that the teaching has been effective? a. "We will need a crash cart available at the client's bedside." b. "We will plan to schedule the anesthesiologist to be available." c. "The medication should be injected over at least 1 to 2 minutes." d. "Infusion of normal saline will be needed before medication injection."

a. "We will need a crash cart available at the client's bedside." Rationale: Adenosine can cause significant bradycardia and short episodes of asystole along with hypotension, so emergency equipment from the crash cart should be at the bedside. Sedation or anesthesia is not needed with adenosine administration. Adenosine is injected over 1 to 3 seconds; slow administration prevents the medication from being effective. A bolus of normal saline is used after adenosine administration to rapidly infuse the medication, but saline is not needed before administration.

Which actions will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. a. Administer oxygen at high flow rates b. Notify the rapid response team c. Lower the head of the client's bed d. Place the client on a cardiac monitor e. Anticipate rapid administration of warfarin

a. Administer oxygen at high flow rates b. Notify the rapid response team d. Place the client on a cardiac monitor Rationale: Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. Cardiac monitoring is needed because the client is at risk for dysrhythmias. The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonary embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin.

After a cardiac catheterization, a client's urinary output is 3 times the client's fluid intake. What is the likely cause of high urinary output? a. An expected effect of the dye used with the procedure b. Increased cardiac output as a result of the procedure c. Improvement of urinary functioning after the catheterization d. A result of the prescribed intravenous (IV) rate of 50 mL/h

a. An expected effect of the dye used with the procedure Rationale: The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; cardiac output will not improve after the procedure. Urinary function does not improve after cardiac catheterization. An IV rate of 50 mL/h will not cause a urinary output three times the amount of intake.

Which information would the nurse include in explaining glaucoma to a client? a. An increase in the pressure within the eyeball b. An opacity of the crystalline lens or its capsule c. A curvature of the cornea that becomes unequal d. A separation of the neural retina from the pigmented retina

a. An increase in the pressure within the eyeball Rationale:An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.

A client who has a lesion in the right upper lobe is diagnosed with tuberculosis (TB). The nurse expects which clinical manifestations? a. Ask the client about medication use and activity level at home b. Suggest discharge to a local assisted living setting with the client c. Teach the client about the importance of limiting home salt intake d. Talk with the client about having home health visits after discharge

a. Ask the client about medication use and activity level at home Rationale: Further assessment of the client's home situation and possible reasons for frequent readmissions are needed before other actions can be taken. Assisted living may be appropriate for the client, but more data are needed before suggesting this option to the client. Teaching the client about limiting salt intake may be appropriate, but the nurse does not know yet why the client has frequent readmissions. Home health visits may be appropriate, but more assessment is needed before a referral can be made.

When a client is admitted with thrombocytopenia, which nursing actions would be included in the plan of care? select all that apply a. Avoid intramuscular injections b. Institute neutropenic precautions c. Monitor the white blood cell (WBC) count d. Administer prescribed anticoagulants e. Examine the skin for ecchymotic areas

a. Avoid intramuscular injections e. Examine the skin for ecchymotic areas Rationale: Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. Neutropenic precautions are for clients with decreased WBCs, not platelets. Platelet count, rather than WBC count, will be monitored. Anticoagulants are contraindicated because of the increased bleeding risk.

Which finding would be of most concern when the nurse is caring for a client who had a femoral-popliteal bypass graft 6 hours previously? a. Blood pressure 192/98 mm Hg b. Sinus rhythm rate 100 beats/minute c. Client report of ongoing incisional pain d. Capillary refill of operative leg at 4 seconds

a. Blood pressure 192/98 mm Hg Rationale: High blood pressure places pressure on the graft incisions and may cause rupture at the graft anastomosis. The health care provider would be notified so that actions to reduce blood pressure could be started. A heart rate at the upper limit of normal will be monitored, but no immediate action is needed. Ongoing incisional pain is not unusual a few hours after surgery; the nurse will assess and treat the pain as prescribed. Slightly longer than normal capillary refill will be monitored, but no other immediate action is needed.

A 78-year-old client comes to the health clinic presenting with fatigue, and laboratory results indicate a hematocrit of 32% and a hemoglobin of 10.5. Which action would the nurse take next? a. Conduct a complete nutritional assessment of the client b. Plan to teach the client about taking daily iron supplements c. Schedule the client to return to have the test repeated in 3 months d. Explain that mild anemia is an expected response to the aging process

a. Conduct a complete nutritional assessment of the client Rationale: A nutritional assessment starts the investigation for a cause of the client's anemia. Although anemia may be caused by iron deficiency, more assessments and testing are needed to establish the etiology of anemia for this client. The client may need to have results repeated in about 3 months, but this will depend on the etiology of the anemia and the treatments that are prescribed. Although mild anemia may occur with aging because of chronic illness, anemia is not considered to be part of the normal aging process and normal hemoglobin and hematocrit values do not change with aging.

Which assessment would the nurse use to assess the client's trigeminal nerve function? a. Corneal sensation b. Facial expressions c. Ocular muscle movement d. Shrugging of the shoulders

a. Corneal sensation Rationale: The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea. Facial expressions (e.g., smiling, frowning) reflect the functioning of cranial nerve VII. The ocular muscle movement tests the function of cranial nerves III, IV, and VI. Shrugging of the shoulders tests the function of cranial nerve XI.

When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority? a. Defibrillate the client b. Notify the rapid response team c. Administer intravenous epinephrine d. Initiate cardiopulmonary resuscitation

a. Defibrillate the client Rationale: When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia. Research indicates that early defibrillation is the strongest indicator for successful resuscitation. The Code 99 or Rapid Response Team will be notified, but the nurse will not wait to notify the team before attempting defibrillation. Epinephrine may be administered if defibrillation is initially unsuccessful, but is not the first action. Cardiopulmonary resuscitation will be started if a defibrillator is unavailable or if initial defibrillation is unsuccessful at ending the ventricular fibrillation.

Which clinical findings would the nurse anticipate for a client who has an exacerbation of multiple sclerosis? select all that apply. a. Double vision b. Resting tremors c. Flaccid paralysis d. Scanning speech e. Intellectual disability

a. Double vision d. Scanning speech Rationale: Diplopia (double vision) and nystagmus (involuntary, rapid, rhythmic eye movements) are experienced by clients with multiple sclerosis as a result of demyelination. Scanning (clipped) speech occurs with multiple sclerosis as a result of demyelination. These clients exhibit the Charcot triad: intention tremor, nystagmus, and scanning speech. Clients experience intention, not resting, tremors. Clients experience spastic paralysis because upper motor neurons are involved. Although emotional affect and speech are affected, intelligence remains intact.

When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. a. Dyspnea b. Crackles c. Frequent cough d. Peripheral edema e. Jugular distention

a. Dyspnea b. Crackles c. Frequent cough Rationale: With left ventricular failure, increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles and cough. Peripheral edema occurs when right-sided heart failure causes increases in systemic venous pressure. Jugular vein distention also occurs with right-sided failure and increased systemic venous pressure.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply a. Ensure the chest tube dressing is tight and intact b. Palpate the skin to detect subcutaneous emphysema c. Place the chest tube drainage system below the chest d. Quickly attempt to reinsert the chest tube if it falls out e. Strip the chest tube with long strokes to promote drainage

a. Ensure the chest tube dressing is tight and intact b. Palpate the skin to detect subcutaneous emphysema c. Place the chest tube drainage system below the chest Rationale: Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgement and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the health care provider. The chest tube should not be stripped because this causes negative pressure that can cause trauma to the pleura.

Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer Disease (AD)? Select all that apply. a. Forgets home address b. Has difficulty multitasking c. Unable to find food in freezer d. Neglects balancing checkbook e. Wear pajama bottoms to store

a. Forgets home address Clients with early-onset AD may forget their home address or be unable to navigate themselves home. Information overload can cause clients to struggle with multitasking, but it is not indicative of AD. Being unable to locate food in the freezer could indicate that the client is experiencing disorganization, but this is not a specific indicator of AD. Neglecting to balance one's checkbook is a fairly common oversight and does not suggest that the client has AD. Wearing pajama bottoms to run a quick errand is common and does not suggest AD.

Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply a. Hair cell degeneration b. Reduced blood supply to the cochlea c. Atrophic changes of the tympanic membrane d. Decline in the ability to filter out unwanted sounds e. Less effective vestibular apparatus in the semicircular canals

a. Hair cell degeneration b. Reduced blood supply to the cochlea e. Less effective vestibular apparatus in the semicircular canals Rationale: Hair cell degeneration, reduced blood supply to the cochlea, and less effective vestibular apparatus in the semicircular canals are assessment findings related to the inner ear. Atrophic changes of the tympanic membrane is an assessment finding associated with the middle ear. A decline in an ability to filter out unwanted sounds is an assessment finding related to the brain.

After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern? a. Have the client sit on the edge of the bed so the nurse can hold the client upright b. Have the client slide to the floor with assistance to avoid injuring the client because of a fall c. Have the client bed forward to increase blood flow to the brain d. Have the client lie down immediately so the nurse may obtain the client's blood pressure (BP)

a. Have the client sit on the edge of the bed so the nurse can hold the client upright Rationale: Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor and bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which will traumatize the spinal cord; taking the BP at this time is not necessary.

After a spontaneous pneumothorax, a client's assessment findings include extreme drowsiness, tachycardia, and tachypnea. The nurse suspects which condition? a. Hypercapnia b. Hypokalemia c. Increased PO2 d. Respiratory alkalosis

a. Hypercapnia Rationale: Pneumothorax results in decreased surface area for gas exchange. If unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client will become drowsy and may lose consciousness. The body attempts to compensate by increasing respiratory and pulse rates and by the kidneys retaining bicarbonate. Hypokalemia causes extreme muscle weakness, abdominal distention, and changes in the electrocardiogram (ECG) pattern. The PO2 is decreased with a pneumothorax because of the decreased surface area for gas exchange. Respiratory acidosis occurs with an elevated PCO2.

Which assessment finding would the nurse document in the client's health record as a positive Romberg test? a. Inability to stand with feet together when eyes are closed b. Fanning of the toes when the sole of the foot is firmly stroked c. Dilation of pupils when focusing on an object in the distance d. Movement of eyes toward the opposite side when head is turned

a. Inability to stand with feet together when eyes are closed Rationale: The Romberg test evaluates proprioception. A client is asked to close the eyes when standing. If balance is lost after the client's eyes are closed, a positive Romberg test suggests that there is a sensory cause. Fanning of toes when the sole of the foot is firmly stroked is a positive Babinski reflex that is indicative of corticospinal pathology in an adult. Dilation of pupils when focusing on an object in the distance is accommodation, a normal finding. Movement of eyes toward the opposite side when the head is turned is the oculocephalic or oculovestibular reflex, a normal finding.

Which instruction will the nurse include when teaching a client who is to wear a Holter monitor 24 hours at home? a. Keep a record of the day's activities b. Avoid going through laser-activated doors c. Record the pulse and blood pressure every 4 hours d. Delay taking prescribed medications until the monitor is removed

a. Keep a record of the day's activities Rationale: The purpose of monitoring is to correlate dysrhythmias with the client's reported activity. Laser-activated doors have no effect on a Holter monitor and will not affect the readings. Recording the pulse and blood pressure every 4 hours is not required for interpretation of the test. The client should take medication as prescribed and note it in the activities diary.

Which type of surgery would be planned for a client with degeneration of the corneal tissue as shown in the figure? a. Keratoplasty b. Cataract removal c. Trabeculectomy d. Laser in situ keratomileusis (LASIK)

a. Keratoplasty Rationale: The pathology figure indicates an abnormal corneal shape, which is caused by degeneration of corneal tissue and is called keratoconus. In cases of misshapen cornea, a keratoplasty (corneal transplant) is performed. This is where the diseased corneal tissue is removed and replaced with tissue from a donor cornea. A cataract is a lens opacity that distorts the image and causes vision impairment. Cataract surgery is performed in clients who have a cataract. A trabeculectomy is performed in clients with glaucoma; glaucoma includes a group of eye disorders that result in increased intraocular pressure. LASIK is the surgical procedure performed to correct eye disorders such as nearsightedness, farsightedness, and astigmatism.

When the nurse is evaluating a client with an acute asthma attack who has just received a nebulizer bronchodilator treatment, which finding requires the most rapid action? a. Labored breathing and absent breath sounds b. Continued high pitched expiratory wheezes c. Use of pursed lip breathing during expiration d. Hyperresonance to percussion of posterior chest

a. Labored breathing and absent breath sounds Rationale: Absent breath sounds and labored appearing respirations indicate that the client has extremely limited airflow and is at risk for respiratory arrest. The nurse would notify the health care provider immediately and anticipate interventions such as intubation, systemic bronchodilators, and mechanical ventilation. Continued high-pitched respiratory wheezes indicate that further treatment is needed, but the client would not be at risk for respiratory arrest. Pursed-lip breathing is frequently used by clients with obstructive airway disease to help improve expiratory effort. Hyperresonance to percussion indicates air trapping in the lungs, but is not an uncommon finding in clients with asthma.

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? a. Shortening and eventual atrophy of the affected muscles will occur b. Hypertrophy of the muscles eventually will result from disuse c. Extension rigidity can occur, making therapy painful and difficult d. Decreased movement on the affected side predisposes the client to infection

a. Shortening and eventual atrophy of the affected muscles will occur Rationale: Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose the client to infection but does predispose the client to muscle atrophy and contractures if there are delays in beginning therapy.

Which action by a 70 year old female client would best limit further progression of osteoporosis? a. Taking supplemental calcium and vitamin D b. Increasing the consumption of eggs and cheese c. Taking supplemental magnesium and vitamin E d. Increasing the consumption of milk products

a. Taking supplemental calcium and vitamin D Rationale: Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis; these foods do not contain vitamin D unless fortified. If large amounts of magnesium are present, calcium absorption is impeded because magnesium and calcium absorption are competitive; vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. Which is an important nursing action? a. Checking for capillary refill b. Encouraging increased fluid intake c. Suctioning secretions from the airway d. Administering a high concentration of oxygen

b. Encouraging increased fluid intake Rationale: Fluids will replace fluid loss from fever and decrease viscosity of secretions. Capillary refill relates to peripheral tissue perfusion. There are no data to suggest that secretions are blocking the airway; there is no support that suctioning is needed. High concentrations of oxygen generally are not administered to clients with chronic obstructive pulmonary disease (COPD); traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduced oxygen levels act as the stimulus and high concentrations of oxygen levels may actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number. The majority of cases involve the Haldane effect; as hemoglobin molecules become more saturated with oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia.

Which phrase describes a greenstick fracture? a. More than two fragments b. Incomplete with one side bent c. Spontaneous, at the site of bone disease d. Across the longitudinal axis of the bone shaft

b. Incomplete with one side bent Rationale: An incomplete fracture with one side splintered and the other side bent indicates a greenstick fracture. A fracture with more than two fragments that appear to be floating is known as a comminuted fracture. A pathological fracture is a spontaneous fracture found at the site of bone disease. A transverse fracture extends across the longitudinal axis of the bone shaft.

A client has a hysterectomy, sapling-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus would the nurse assess the client? select all that apply. a. Flushed face b. Increased temperature c. Severe abdominal pain d. Decreased oxygen saturation e. Sudden onset of shortness of breath

b. Increased temperature d. Decreased oxygen saturation e. Sudden onset of shortness of breath Rationale: When perfusion in the lung is interrupted, the exchange of carbon dioxide and oxygen is impaired; as a result, the client's oxygen saturation level will decrease. Because an embolus interferes with capillary perfusion in the alveoli, the transfer of oxygen into the blood and carbon dioxide out of the blood is impaired, so the client becomes short of breath. An increase in body temperature may occur. A flushed face is not a clinical manifestation of a pulmonary embolus. Abdominal pain is related to the surgical procedure. A sudden onset of mild to severe, and often sharp, chest pain can be associated with a pulmonary embolus.

Which physiological response explains why elevation in body temperature occurs in clients who experience acute coronary syndrome? a. Parasympathetic reflexes b. Inflammatory response c. Catecholamine release d. Peripheral vasoconstriction

b. Inflammatory response Rationale: Temperature may increase within the first 24 hours after acute coronary syndrome as a result of the inflammatory response to tissue destruction and persist as long as a week. Parasympathetic activity caused by vagal stimulation might cause bradycardia in clients with acute coronary syndrome. Catecholamine release associated with acute coronary syndrome might cause hypertension or dysrhythmias such as atrial or ventricular tachycardia and ventricular fibrillation. Peripheral vasoconstriction associated with acute coronary syndrome may cause prolonged capillary refill, decreased peripheral pulse quality, or cool skin.

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different from full-thickness burns. Which information did the nurse recall? a. Partial-thickness burns require grafting before they can heal b. Partial-thickness burns are often painful, reddened, and have blisters c. Partial-thickness burns cause destruction of both the epidermis and dermis d. Partial-thickness burns often take months of extensive treatment before healing

b. Partial-thickness burns are often painful, reddened, and have blisters Rationale: Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.

When a client injures the amphiarthrodial joint, which joint did the client injure? a. Knee joint b. Pelvic joint c. Elbow joint d. Cranial joint

b. Pelvic joint

Which goal is the nurse trying to achieve by reinforcing to the client that it is important to seek treatment for primary open-angle glaucoma (POAG)? a. Prevent cataracts b. Prevent blindness c. Prevent retinal detachment d. Prevent blurred distance vision

b. Prevent blindness Rationale: POAG progresses gradually without symptoms; if untreated, blindness occurs. Peripheral vision slowly disappears until tunnel vision occurs in which there is only a small center field. Without treatment, eventually all vision is lost. POAG is not related to the development of cataracts, retinal detachment, or blurred distance vision.

When a client who is admitted for coronary artery bypass graft (CABG) surgery asks the nurse about the purpose of pacemaker wires inserted during surgery, which explanation will the nurse give? a. Defibrillation of the heart after surgery b. Prevention of slow heart rate after surgery c. Maintenance of rate of at least 100 beat/minute during surgery d. Inhibition of too-rapid heart rate during the postoperative period

b. Prevention of slow heart rate after surgery Rationale: Pacing wires are sometimes placed during CABG so that pacing is rapidly available in case of bradycardia during the postoperative period. Pacing wires are not use for defibrillation. The heart is usually placed into cardiac arrest during CABG to facilitate the suturing of grafts into place. Medications to slow heart rate would be used rather than overdrive pacing during the postoperative period after CABG.

Which physiological factors help maintain blood pressure in the client with hypovolemia? Select all that apply. a. Arteriolar dilation b. Release of aldosterone c. Activation of angiotensin II d. Sympathetic nervous system activation e. Stimulation of the vagus nerve

b. Release of aldosterone c. Activation of angiotensin II d. Sympathetic nervous system activation Rationale: In hypovolemia, aldosterone, angiotensin II, and sympathetic nervous system activation all increase blood pressure. Release of aldosterone from the adrenal cortex causes retention of sodium and water, which increases blood volume and blood pressure. Angiotensin II activation causes vasoconstriction, which raises blood pressure. Sympathetic nervous system activation increases heart rate and left ventricular contractility and also causes vasoconstriction. Arteriolar dilation would tend to decrease blood pressure. Vagus nerve stimulation leads to a decrease in heart rate, which tends to decrease blood pressure.

Which assessment finding for a client who is anxious indicates sympathetic nervous system stimulation? a. Dry skin b. Skin pallor c. Pupil constriction d. Bradycardia

b. Skin pallor Rationale: The sympathetic nervous system constricts the smooth muscle of blood vessels in the skin when a person is under stress, thereby causing skin pallor. The sympathetic system stimulates, rather than inhibits, secretion by the sweat glands. Constriction of pupils is not under sympathetic control; the parasympathetic system constricts the pupils. The parasympathetic system (vagus nerve) slows the pulse, and the sympathetic system increases it.

After a client has a bone marrow aspiration performed, which action would the nurse take first? a. Position the client on the affected side b. Administer prescribed analgesics for pain c. Apply firm pressure over the aspiration site d. Monitor the client's blood pressure and pulse

c. Apply firm pressure over the aspiration site Rationale: The initial action will be to hold pressure over the site until bleeding stops. The other actions are also needed after the nurse has assured that bleeding has stopped. Clients are positioned on the side of the procedure to apply pressure to the aspiration site, which will decrease bleeding risk. If clients report pain after the procedure, analgesics are given as prescribed. Because clients having a bone marrow aspiration may be thrombocytopenic and bleeding may recur after the procedure, the nurse will monitor blood pressure and pulse and assess the site for bleeding at frequent intervals.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. a. Switch positions every 4 hours b. Use a heating pad for first 24 hours c. Apply for 30 minute time intervals d. Place the ice pack directly to injury site e. Take ibuprofen every 4 hours PRN

c. Apply for 30 minute time intervals Rationale: To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

Which type of bone tumor occurs most commonly in elderly clients? a. Endochroma b. Osteosarcoma c. Chondrosarcoma d. Osteochondroma

c. Chondrosarcoma Rationale: Chondrosarcoma occurs most commonly in cartilage in the arm, leg, and pelvic bones of older adults in the age group of 50 to 70 years old. Endochroma occurs in clients in the age group of 10 to 20 years old. Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old.

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

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

A client sustains fractured ribs as a result of an accident. Which clinical indicator suggests the client may be experiencing a complication of fractured ribs? a. Report of pain when taking deep breaths b. Client is observed splinting the fracture site c. Diminished breath sounds on the affected side d. Bowel sounds are auscultated in the lower chest

c. Diminished breath sounds on the affected side Rationale:

The nurse is caring for a client with an endotracheal tube. What is the most effective way for for the nurse to loosen respiratory secretions? a. Increase oral fluid intake b. Provide chest physiotherapy c. Humidify the prescribed oxygen d. Instill a saturated solution of potassium iodide

c. Humidify the prescribed oxygen Rationale: Because the client has an endotracheal tube in place, secretions can be loosened by administering humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs.

The nurse is teaching a community health class about the risk factors for cancer of the larynx. Which factor has the least influence in predisposing an individual to this type of cancer? a. Air pollution b. Heavy alcohol ingestion c. Inadequate dental hygiene d. Chronic respiratory infection

c. Inadequate dental hygiene Rationale: Inadequate dental hygiene may predispose a person to oral infections but is involved only remotely in laryngeal neoplasms because of the anatomical relationship of the oral cavity and the larynx. Irritation by air pollutants may initiate tissue changes that can lead to malignancy. Alcohol is an irritant that may initiate tissue changes that result in a malignant neoplasm. Tissue alterations caused by repeated microbiological stress may result in a malignant neoplasm.

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is a loss of taste perception from the anterior two thirds region of the tongue. Which origin of the brain is associated with the involves nerve? a. Medulla b. Midbrain c. Inferior pons d. Cerebrum

c. Inferior pons Rationale: Loss of taste perception from the anterior two-thirds of the tongue indicates injury to the facial nerve, which originates from the inferior pons. The medulla is the site of origin for the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The optic nerve and oculomotor nerve originate from the midbrain. The site of origin for the olfactory nerve is the olfactory bulb in the anterior ventral cerebrum.

Which action would the nurse take when administering a transfusion of 2 units of packed red blood cells (PRBCs) to a client? a. Infuse lactated ringer's solution with the PRBCs b. Warm the blood to 98 degrees F to prevent chills c. Infuse the blood at a slow rate during the first 15 minutes d. Draw blood samples from the client after each unit is transfused

c. Infuse the blood at a slow rate during the first 15 minutes Rationales: A slow rate provides time to recognize a reaction that is developing before too much blood is administered. Normal saline may be infused with blood, but lactated Ringer's solution will cause red blood cell hemolysis. Blood is not warmed to 98°F (36.7°C) to prevent chills; this could cause clotting and hemolysis. Drawing blood samples from the client after each unit is transfused is not necessary.

During a client's immediate postoperative period after a laryngectomy, which is a nursing priority? a. Provide emotional support b. Observe for signs of infection c. Keep the trachea free of secretions d. Promote a means of communication

c. Keep the trachea free of secretions Rationale: A patent airway is the priority; therefore removal of secretions is necessary. Providing emotional support is important but not the priority immediately after surgery. Observing for signs of infection is an important postoperative concern but does not occur immediately. Although important, promoting a means of communication is not as important as a patent airway.

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast? a. Renal failure b. Claustrophobia c. Metal aneurysm clips d. Soft tissue imaging needs

c. Metal aneurysm clips Rationale: Any implanted metal is contraindicated to enter the MRI area because MRI machines use a powerful magnet. Renal failure is not necessarily a contraindication to MRI with contrast because the MRI contrast agent gadolinium is not nephrotoxic. Open MRI is an option for claustrophobic clients, although this type of imaging may not be a good as traditional MRI. Soft tissue is captured well by MRI—it is bone that is not well visualized by this form of imaging.

Which organism infestation is diagnosed with the help of the mineral oil test? a. Lice b. Ticks c. Mites d. Fungus

c. Mites Rationale: Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically

A client who has a lesion in the right upper lobe is diagnosed with tuberculosis (TB). The nurse expects which clinical manifestations? a. Frothy sputum and fever b. Dry cough and pulmonary congestion c. Night sweats and blood tinged sputum d. Productive cough and engorged neck veins

c. Night sweats and blood tinged sputumf Rationale: Blood-tinged sputum is often the presenting sign of TB; diaphoresis at night is a later sign. Frothy sputum occurs with pulmonary edema. Engorged neck veins occur with right heart failure. Pulmonary congestion is characteristic of heart failure or pulmonary edema.

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider? a. Severe right calf pain b. Right calf redness and swelling c. Oxygen saturation 89% d. Heart rate 136 beats/minute

c. Oxygen saturation 89% Rationale: ow oxygen saturation in the setting of venous thrombosis may indicate pulmonary embolism, which will require rapid interventions, such as actions to improve oxygenation. Severe right calf pain is consistent with the client diagnosis of right calf venous thrombosis. Right calf redness and swelling are consistent with a diagnosis of right calf venous thrombosis. The elevated heart rate may be due to pulmonary embolism, and improvement of oxygen saturation would also decrease the heart rate.

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? a. Proteus b. Bacteroides c. Pseudomonas d. Staphylococcus

c. Pseudomonas Rationale: The purulent exudates of greenish-blue pus with a fruity odor signifies colonization with Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.

What action would the nurse include in the plan for care of a client on the first postoperative day after a radical neck dissection for laryngeal cancer? a. Reposition the nasogastric tube as needed b. Avoid suctioning the mouth or tracheostomy c. Limit use of the client's shoulders and upper arms d. Keep the client in semi-fowler position when in bed

d. Keep the client in semi-fowler position when in bed Rationale: Keeping the head elevated at 30 to 45 degrees reduces swelling and minimizes tension on suture lines. When a nasogastric is used after radical neck surgery, it is located close to internal incisions and should not be moved or manipulated. The mouth and tracheostomy may need suctioning if the client is unable to effectively expel secretions by coughing. Because the spinal accessory nerve and sternocleidomastoid muscles are removed during a radical neck procedure, it is important that the client begin using the shoulder and arm to maximize return to function.

When the nurse is assessing a client with osteolytic lesions caused by multiple myeloma, which finding will be most important to communicate to the health care provider? a. Bruising at injection sites b. Calcium level 10.2 mg/dL c. Elevated urine protein level d. New onset weakness in both legs

d. New onset weakness in both legs Rationale: Because osteolytic lesions can lead to pathologic fractures, including vertebral collapse and pressure on the client's spinal cord, the nurse would immediately report new onset leg weakness to the health care provider. The other findings are associated with multiple myeloma, but do not indicate a need for immediate action to prevent complications. Bruising at injection sites is likely because of thrombocytopenia caused by the disease process or by chemotherapy. The client's serum calcium level is normal, but calcium levels are monitored because osteolysis can cause hypercalcemia. Urine protein levels are elevated because of the high level of abnormal Bence-Jones protein seen with multiple myeloma.

Which arterial blood gas result for a client who is receiving mechanical ventilation using the pressure support ventilation mode indicates that the client is hyperventilating? a. pH 7.28 b. Bicarbonate (HCO3) 24 mEq/L c. Partial pressure of oxygen (PaO2) 60 mmHg d. Partial pressure of carbon dioxide (PaCO2) 30 mmHg

d. Partial pressure of carbon dioxide (PaCO2) 30 mmHg Rationale: The normal PaCO2 is 35 to 45 mm Hg. Hyperventilation leads to elimination of carbon dioxide, lowering of PaCO2, and causing respiratory alkalosis. A pH of 7.28 would indicate acidosis. An HCO3 of 24 is in the normal range of 21 to 27 mEq/L and would not be consistent with hyperventilation. PaO2 is not directly affected by respiratory rate or depth, and the of PaO2 of 60 could occur with normal rate and depth of ventilation or with either hypoventilation or hyperventilation.

Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? a. Encourage frequent coughing b. Elevate the client's lower extremities c. Prepare for modified postural drainage d. Place the client in the orthopneic position

d. Place the client in the orthopneic position Rationale: The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Coughing is useful for clients who have excessive mucus in the airways, such as clients with pneumonia, but is not useful for clearing pulmonary edema. Elevation of the extremities should be prevented because it increases venous return, placing an increased workload on the heart. Positioning for postural drainage does not relieve acute dyspnea; furthermore, it increases venous return to the heart.

When a client is scheduled for an emergency splenectomy after a traumatic injury, which topic would the nurse include in preoperative teaching? a. Probability of wound dehiscence b. Safety aspects of this type of surgery c. Expectation of postoperative bleeding d. Presence of abdominal drains for several days

d. Presence of abdominal drains for several days Rationale: Drains usually are inserted into the splenic bed to facilitate removal of fluid that can lead to abscess formation. The risk for wound dehiscence is no greater than for any other abdominal surgery. Discussion of safety aspects of this type of surgery is the role of the health care provider. Bleeding may occur after splenectomy, but the nurse would not teach that bleeding is "expected."

When caring for a client who is hospitalized for an acute myocardial infarction, which prescription by the health care provider would the nurse question? a. Long-acting beta blocker b. Daily low-dose aspirin tablet c. H1 blocker to reduce gastric acid secretions d. Rectal suppository as needed for constipation

d. Rectal suppository as needed for constipation Rationale: Rectal stimulation can stimulate the vagus nerve and cause bradycardia and is avoided in clients who have had myocardial infarction. Long-acting beta blockers are commonly prescribed after myocardial infarction to prevent cardiac remodeling and heart failure. Low-dose aspirin is typically prescribed to clients with coronary artery disease or myocardial infarction to prevent new coronary artery thrombus from forming. H1 blockers are frequently prescribed to hospitalized clients to prevent formation of stress-related gastric ulcers.

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? a. Tenting b. Angioma c. Varicosity d. Telangiectasia

d. Telangiectasia Rationale: Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated. Tenting is the failure of the skin to immediately return to the normal position after a gentle pinch. Angioma is a tumor that consists of blood and lymph vessels. Varicosity is the increased prominence of superficial veins.

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

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

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? a. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula b. Place the client in a side lying position and perform chest physiotherapy using clapping and vibration c. Raise the head of the bed to a high fowlers position and administer 2 L/min oxygen per nasal cannula d. Assist the client in assuming a position of comfort and perform postural drainage

c. Raise the head of the bed to a high fowlers position and administer 2 L/min oxygen per nasal cannula Rationale: Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.

When encouraging a client to seek testing and treatment for streptococcal pharyngitis, which complication will the nurse discuss? a. Asthma b. Anemia c. Rheumatic fever d. Reye syndrome

c. Rheumatic fever Rationale: Rheumatic fever is caused by an abnormal immunological response to group A beta-hemolytic streptococcus, which may cause permanent scarring and damage to the heart valves (rheumatic heart disease). Asthma, anemia, and Reye syndrome are not caused by beta-hemolytic streptococcus.

Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter? a. Sit up straight in a firm chair b. Check peak flow early in the morning c. Take the deepest breath you can, then blow out hard and fast d. Calculate the average of 3 readings to obtain your peak flow

c. Take the deepest breath you can, then blow out hard and fast Rationale: A peak flow meter measures the peak expiratory flow rate and is used by taking the deepest breath possible, then forcefully exhaling as quickly as possible. The client is taught to stand when measuring peak flows to assure accurate readings. Peak flow measurements should be done between noon and 2:00 PM when peak flows are highest. The peak flow reading is done 3 times, and the highest reading is recorded as the peak flow.

Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider? a. High anxiety level b. Elevated troponin T c. Urine output 15 mL/h d. Heart rate 58 beats/minute

c. Urine output 15 mL/h Rationale: Heart failure is a common complication after myocardial infarction, and a low urine output may indicate left ventricular failure, which would require immediate collaborative actions such as administration of diuretics or diagnostic testing such as echocardiography. Anxiety is a normal response to stressful events such as myocardial infarction and does require action by the nurse, but is not life-threatening. An elevation in troponin T is expected with myocardial infarction. A heart rate of 58 beats/minute is very slightly below normal and heart rate will continue to be monitored by the nurse, but does not require immediate notification of the health care provider.

When assessing a client with a diagnosis of left ventricular failure, which statement by the client would the nurse expect? a. "My ankles are swollen" b. "My appetite is not very good" c. "When I eat a large meal, I feel bloated" d. "I have trouble breathing when I walk rapidly"

d. "I have trouble breathing when I walk rapidly" Rationale: Dyspnea (difficulty breathing) on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "My appetite is not very good" is more consistent with right ventricular failure. The statement "When I eat a large meal, I feel bloated" is more typical with right ventricular failure.

Which information would the nurse include in postprocedure teaching for a client who had sclerotherapy for varicose veins? a. "Limit activity until edema subsides" b. "Remove compression bandages when in bed" c. "Place a pillow under the knees when lying in bed" d. "Walk for several minutes every hour when awake"

d. "Walk for several minutes every hour when awake" Rationale: Walking activities are encouraged to improve circulation and dilute the sclerosing agent. Limiting activity is contraindicated; inactivity contributes to venous stasis and engorgement of veins. Compression bandages should be left in place for several days to ensure external compression of veins, which enhances venous return. Placing a pillow under the knees when lying in bed is contraindicated because it will impede venous return.

A 50 year old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident. When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? a. Ask the spouse how to know the client's feelings b. Instruct the spouse to let the client answer c. When the spouse leaves, return to speak with the client d. Acknowledge the spouse, but look at the client for a response

d. Acknowledge the spouse, but look at the client for a response Rationale: The client must have the opportunity to practice language skills; family participation must be accepted and recognized. The spouse should be included and involved in the client's care. Asking the wife how she knows the client's feelings, instructing the wife to let the client answer for himself, and returning to speak with the client when the wife leaves, demeans the spouse and cuts off communication.

When the thigh-high anti embolism stockings that have been prescribed for a client with varicose veins fit on the lower legs but are too small to fit over the thighs, which action would the nurse take? a. Slightly slit the top of the stockings to relieve pressure b. Leave the antiembolism stocking off to prevent tissue damage c. Roll the top of the stocking to below the knees to limit popliteal pressure d. Ask the healthcare provider if an elastic bandage can be used in place of the stockings

d. Ask the healthcare provider if an elastic bandage can be used in place of the stockings Rationale: An elastic bandage can be adjusted to the varying proportions of the client's legs. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.

Which assessment strategy would the nurse use to evaluate sensory changes in a client whose spinal cord was severed at the level of T6 and T7? a. Monitoring the client's vital signs trends b. Instructing the client to squeeze the nurse's hand c. Observing the skin for color changes below the lesion d. Asking the client to state where the pinching sensation is felt

d. Asking the client to state where the pinching sensation is felt Rationale: Because the client must describe sensations, the nurse must involve the client in this assessment. Squeezing the nurse's hand will not elicit what the client feels; it determines motor function. Monitoring vital signs cannot identify sensory changes. Changes in skin color may be a response to sensations such as heat or cold, but not to pain, anesthesia, or paresthesias.

Which action would the nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram? a. Elevate the foot of the bed b. Place in the high fowler position c. Perform urinary catheterization care every 12 hours d. Check pedal pulses every 15 minutes postprocedure

d. Check pedal pulses every 15 minutes postprocedure Rationale: Because of the risk for bleeding or obstruction of femoral artery flow after femoral angiograms, pedal pulses are checked every 15 minutes for the first hour postprocedure. Clients with peripheral arterial disease should keep the feet slightly lower than the heart to promote perfusion. Urinary catheters are not typically needed after a femoral angiogram procedure. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.

The nurse is caring for a client 36 hours after the insertion of a chest tube. The tube is attached to a three-chamber, closed chest drainage system. The nurse identifies that the water in the underwater seal tube is not fluctuating. Which action should the nurse take? a. Take the client's vital signs b. Inform the health care provider c. Turn the client to the unaffected side d. Check the tube to ensure that it is not kinked

d. Check the tube to ensure that it is not kinked Rationale: Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the health care provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.

The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under the water while auscultating the lungs of a client with chronic obstructive pulmonary disease. Which sounds would the nurse document in the client's assessment record? a. Rhonchi b. Wheezes c. Fine crackles d. Coarse crackles

d. Coarse crackles Rationale: A series of long, discontinuous low-pitched sounds similar to blowing through straw under water indicates coarse crackles. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways. Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction. Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.

Which finding would the nurse expect when caring for a client with right sided heart failure? a. Oliguria b. Pallor c. Cool extremities d. Distended neck veins

d. Distended neck veins Rationale: Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria is caused by decreased renal perfusion associated with left ventricular failure. Pallor is caused by decreased systemic perfusion secondary to left ventricular failure. Cool extremities are a symptom of decreased systemic perfusion associated with left ventricular failure.

Which action would the nurse take when caring for an older adult with a history of recent memory loss? a. Instruct the client to move slowly when changing positions b. Remind the client to look where he or she places the feet while walking c. Adjust the daily schedule to accommodate sleep pattern d. Employ electronic devices that provide alerts

d. Employ electronic devices that provide alerts Rationale: Providing electronic devices that give alerts can help an older adult who has developed recent memory loss. Adjusting the daily schedule can aid older adults who have changes in their sleep pattern. Instructing the client to move slowly when changing positions can prevent dizziness and falls caused by orthostatic blood pressure changes or altered balance/coordination. Reminding the client to check where the feet are placed can help older adults with a decreased sensory perception of touch.