Test 1 medsurg

A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions?

Serum potassium of 2.6 mEq/L (2.6 mmol/L) Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and would cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug?

"Do you have any allergy to sulfa drugs?" Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? Left lateral Prone Right lateral Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"I will take this medication with my breakfast each morning." Adalimumab is an immune modulator that is given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

A nurse cares for a young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond?

"Let's talk to the ostomy nurse about options for ostomy supplies and dress styles."

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? "Changes in your liver cause drugs to be metabolized differently." "Perhaps you don't need as high a dose of the drug as before." "Stomach muscles atrophy with age and you digest more slowly." "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug? "Have you been experiencing any constipation?" "Are you eating a diet high in fiber and fluids?" "Do you have a history of high blood pressure?" "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse would assess the client for constipation because it places the client at risk for this complication. The other questions do not identify the risk for complications related to alosetron.

The nurse delegates completing a bladder scan to assistive personnel (AP). Which action by the AP indicates that the nurse must provide additional instructions when delegating this task? Selecting the female icon for all female patients and male icon for all male patients Telling the client, "This test measures the amount of urine in your bladder." Applying ultrasound gel to the scanning head and removing it when finished Taking at least two readings using the aiming icon to place the scanning head

ANS: A The AP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the AP should choose the male icon. The AP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What drug would the nurse anticipate to be prescribed for this client? Calcium acetate Doxycyline Magnesium sulfate Lisinopril

ANS: A The client with CKD often has a high phosphorus level which tends to lower the calcium level in an inverse relationship, and causes osteodystrophy. To prevent this bone disease, the client needs to take a drug that can bind with phosphorus for elimination via the GI tract. When phosphorus is lowered to within normal limits, normal calcium levels may be restored.

The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? Pale and bluish stoma Liquid stool Ostomy pouch intact Blood-tinged output

ANS: A The nurse would assess the stoma for color and contact the primary health care provider if the stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.) Client with prostate cancer Client with blood clots in the urinary tract Client with ureterolithiasis Client with severe burns Client with lupus

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI.

The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) Apply ice to the surgical area for the first 24 hours after surgery. Encourage ambulation with assistance within the first few hours after surgery. Encourage deep breathing after surgery but teach the client to avoid coughing. Assess vital signs frequently for the first few hours after surgery. Teach the client to rest for several days after surgery when at home. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.

ANS: A, B, C, D, E, F All of these nursing actions are appropriate for the client having MIS for inguinal hernia repair.

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) Does your gym provide yoga classes? When should you contact your provider? What do you plan to eat for dinner? Do you have a scale for daily weights? How many bathrooms are in your home?

ANS: A, B, C, E A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client's knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.

The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) Contour of the abdomen when standing Location of the client's belt line Contour of the abdomen when lying Location of abdominal muscles Contour of the abdomen when sitting

ANS: A, B, C, E Before marking the placement for the ostomy, the nurse would consider the contour of the abdomen in lying, sitting, and standing positions, the location of the belt line and possible location in the rectus muscle. The location of abdominal muscles is not considered.

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) Lower gastrointestinal bleeding—erosion of the bowel wall Abscess formation—localized pockets of infection develop in the ulcerated bowel lining Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer Fistula—dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.) "You will not need vascular access to perform PD." "There is less restriction of protein and fluids." "You will have no risk for infection with PD." "You have flexible scheduling for the exchanges." "It takes less time than hemodialysis treatments."

ANS: A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis.

A client is undergoing hemodialysis. The client's blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions would the nurse perform to maintain blood pressure? (Select all that apply.) Adjust the rate of extracorporeal blood flow. Place the patient in the Trendelenburg position. Stop the hemodialysis treatment. Administer a 250-mL bolus of normal saline. Contact the primary health care provider.

ANS: A, B, D Hypotension occurs often during hemodialysis treatments as a result of vasodilation from the warmed dialysate. Modest decreases in blood pressure, as is the case with this client, can be maintained with rate adjustment, Trendelenburg positioning, and a fluid bolus. If the blood pressure drops considerably after two boluses and cooling dialysate, the hemodialysis can be stopped and the primary health care provider contacted.

A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse identify as normal? (Select all that apply.) pH: 6 Specific gravity: 1.015 Protein: 1.2 mg/dL Glucose: negative Nitrate: small Leukocyte esterase: positive

ANS: A, B, D The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) Obtain vital signs every 15 to 30 minutes until alert. Assess the client for rectal bleeding and severe pain. Administer prescribed pain medications as needed. Monitor the client's serum and urine glucose levels. Confirm the client has a ride home and plans to rest.

ANS: A, B, E During the recovery phase after a colonoscopy, the nurse would obtain vital signsevery 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) Nausea and vomiting Distended rigid abdomen Abdominal pain Bradycardia Decreased urinary output Fever

ANS: A, C, D, E, F Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury? (Select all that apply.) Urine output of 100 mL in 4 hours Urine output of 500 mL in 12 hours Large amount of sediment in the urine Amber, odorless urine Blood pressure of 90/60 mm Hg

ANS: A, C, E The low urine output, sediment, and blood pressure would be reported to the primary health care provider. Postoperatively, the nurse would measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hr for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours would be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.) Colonoscopy every 10 years Endoscopy every 5 years Computed tomography (CT) colonography every 5 years Double-contrast barium enema every 10 years Flexible sigmoidoscopy every 5 years

ANS: A, C, E The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate? Give the client a bottle of water immediately. Start an intravenous line for fluids. Teach the patient to drink 2 to 3 L of water daily. Perform an electrocardiogram.

ANS: AThis athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be needed later, after the patient's degree of dehydration is assessed. An electrocardiogram is not necessary at this time.

A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How would the nurse respond? "Your friends will be happy that you are alive." "Tell me more about your concerns." "A therapist can help you resolve your concerns." "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse would encourage the client to discuss concerns by restating them in an open-ended manner. The nurse would not minimize the client's concerns or provide false reassurance.

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? "Use warm compresses on the client's abdomen continuously." "Avoid washing the client's abdomen too aggressively." "Apply ice to the client's abdomen every 4 hours." "Massage the client's abdomen to help reduce pain."

ANS: B A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client's abdomen very gently.

The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement by the client indicates a need for further teaching? "I should have less pain after this surgery compared to having a large incision." "I will probably be in the hospital for 3 to 4 days after surgery." "I will be able to walk around a little on the same day as the surgery." "I will be able to return to work in a week or two depending on how I do."

ANS: B All of these statements are correct about having minimally invasive laparoscopic surgery except that the hospital stay will likely be only 1 or 2 days.

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding? Client with a blood pressure of 158/90 mm Hg Client with Kussmaul respirations Client with skin itching from head to toe Client with halitosis and stomatitis

ANS: B Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most patients with CKD, and skin itching increases with calcium-phosphate imbalances and elevations of nitrogenous wastes, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatitis.

A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the test? "This test will determine whether you have colorectal cancer." "You need to avoid red meat and NSAIDs for 48 hours before the test." "You don't need to have this test because you can have a virtual colonoscopy." "This test can determine your genetic risk for developing colorectal cancer."

ANS: B The FOBT is a screening test that is sometimes used to assess for microscopic lower GI bleeding. To help prevent false positive results, the client needs to avoid red meat, Vitamin C, and NSAIDs. The test is not diagnostic nor does it determine a client's genetic risk for colorectal cancer.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? Allow the client cool liquids only. Assess the client's gag reflex. Remind the client to remain NPO. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure depresses the client's gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) Alanine aminotransferase: biliary system Ammonia: liver Amylase: liver Lipase: pancreas Urine urobilinogen: stomach

ANS: B,D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? Paralytic ileus Bowel volvulus Sepsis Colitis

ANS: C The client who has a strangulated inguinal hernia would likely develop bowel necrosis which can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as fever, tachypnea, and tachycardia. If the client's condition is not promptly managed, bowel perforation, septic shock, and death can result.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? Ask the client to call back if this happens again today. Instruct the client to go to the emergency department. Remind the client that a small amount of bleeding is possible. Tell the client to come to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0-10." Which action would the nurse take first? Reposition the client on the operative side. Administer the prescribed opioid analgesic. Assess the client's pulse rate and blood pressure. Examine the color of the client's urine.

ANS: C An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of possible internal hemorrhage. A change in vital signs (elevated pulse and decreased blood pressure) can indicate that hemorrhage is occurring.

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time? Teach the client about the purpose of the MRI. Assess the client's blood urea nitrogen and creatinine. Tell the client to withhold metformin for 24 hours before the MRI. Ask the client if he or she is taking antibiotics.

ANS: C Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage.

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? Culture and sensitivity Parasites and ova Occult blood test Total fat content

ANS: C Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond? "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." "Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density." "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood."

ANS: C Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency. The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.

A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation would the nurse teach the client? "Eat low-fiber and low-residual foods." "White rice and bread are easier to digest." "Add vegetables such as broccoli and cauliflower to your diet." "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client would be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? Palpating the access site for a bruit or thrill Using the right arm for a blood pressure reading Administering intravenous fluids through the AV fistula Checking distal pulses in the left arm

ANS: C The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? Steatorrhea Ulcerative colitis Crohn disease Lactose intolerance

ANS: D The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose.

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client's 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours? 380 mL 500 mL 620 mL 750 mL

ANS: C The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance.

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 Potassium 5 Blood urea nitrogen (BUN) 44 Serum creatinine 2.5 What initial intervention would the nurse anticipate? Start hemodialysis immediately. Discuss the need for peritoneal dialysis. Increase the dose of immunosuppression. Return the client to surgery for exploration.

ANS: CThe client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer? A 37-year-old who drinks eight cups of coffee daily. A 44-year-old with irritable bowel syndrome (IBS). A 60-year-old lawyer who works 65 hours per week. A 72-year-old who eats fast food frequently.

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

A nurse reviews the urinalysis of a client and notes the presence of glucose. What action would the nurse take? Document findings and continue to monitor the client. Contact the primary health care provider and recommend a 24-hour urine test. Review the client's recent dietary selections over 3 days. Perform a finger stick blood glucose assessment.

ANS: D Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL (12.2 mmol/L), which means that a person whose blood glucose is less than 220 mg/dL (12.2 mmol/L) will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a blood glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor are not appropriate. Requesting a 24-hour urine test or reviewing the client's dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler

ANS: D Having the client in a semi-sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing.

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action? Calculate the mean arterial pressure (MAP). Ask for insertion of a pulmonary artery catheter. Take the client's pulse. Decrease the rate of the IV infusion.

ANS: D The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug's effectiveness? a. Potassium b. Sodium c. Renin d. Hemoglobin

ANS: D The purpose of giving epoetin alfa to a client with CKD is to manage anemia by stimulating the bone marrow to produce more red blood cells. Therefore, monitoring the client's hemoglobin, hematocrit, and red blood cell count would indicate if the drug was effective.

A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include?

"You should be able to have better bowel continence after healing occurs."

The nurse is preparing a client for a percutaneous kidney biopsy. Which laboratory tests results would the nurse review prior to the procedure? (Select all that apply.) Hemoglobin Hematocrit Sodium Potassium Platelet count Prothrombin time

ANS: A, B, E, F Kidneys are very vascular and the client is at risk for bleeding after a biopsy. Therefore, it is essential that the nurse review preprocedure laboratory test results for anemia and coagulation problems

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care? Edema and pain Cardiac and respiratory status Electrolyte and fluid imbalance Mental health status

ANS: CThis client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first?

Heart rate and rhythm Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? Depth of respirations Bowel sounds Grip strength Electrocardiography

ANS: A A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A new registered nurse asks the registered nurse (RN) preceptor what could be done to become more professional. What is the preceptor's best response? "Attend nursing educational meetings." "Listen to other nurses." "Read the agency newsletter." "Pass the licensing exam."

ANS: A Knowledge and commitment are essential components of professionalism. Attending nursing educational meetings can promote collaborative learning with peers and maintenance of competence in an ever-changing healthcare environment. Listening can promote professionalism, and communication is certainly a component of professionalism; however, there is also a social sense to listening, and without the educational/learning component, this is not the best answer. An agency newsletter could include information about professional opportunities, but it is not the best answer. The new nurse would have already passed the licensing exam, the legal requirement to be considered a nurse.

A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse? Place the client on a cardiac monitor immediately. Teach the client to limit high-potassium foods. Continue to monitor the client's intake and output. Ask to have the laboratory redraw the blood specimen.

ANS: A The best action by the nurse would be to check the cardiac status with a monitor. High-potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? Discuss what the treatment regimen means to the client. Refer the client to a mental health nurse practitioner. Reschedule the appointments to another date and time. Discuss the option of peritoneal dialysis.

ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment would come first.

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How would the nurse respond? "The stool will always be liquid with this type of colostomy." "Eating additional fiber will bulk up your stool and decrease diarrhea." "Your stool will become firmer over the next couple of weeks." "This is abnormal. I will contact your primary health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

Components of a professional identity in nursing include which attributes? (Select all that apply.) Doing Being Acting ethically Flourishing Culture

ANS: A, B, C, D The scope of professional identity in nursing includes: doing, being, acting ethically, flourishing and changing identities. Cultural sensitivity is important to professional nursing; however, culture is an inherent quality of nurses and patients, not a component of the professional identity.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) Attend hand-off rounds to coach and mentor. Create a template of suggested topics to include in report. Encourage staff to ask questions during hand-off. Give raises based on compliance with reporting. Provide education on the SBAR method of communication

ANS: A, B, C, E The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) Decreased hydrochloric acid production Diminished sensation that can lead to constipation Fat not digested as well in older adults Increased peristalsis in the large intestine Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) Hypokalemia—muscle weakness with respiratory depression Hypermagnesemia—bradycardia and hypotension Hyponatremia—decreased level of consciousness Hypercalcemia—positive Trousseau and Chvostek signs Hypomagnesemia—hyperactive deep tendon reflexes Hypernatremia—weak peripheral pulses

ANS: A, B, C, E, F Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) Corn String beans Carrots Wheat rice Squash

ANS: A, B, D Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) Increased pulse rate Distended neck veins Decreased blood pressure Warm and pink skin Skeletal muscle weakness Visual disturbances

ANS: A, B, E, F Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) Calculate pulse pressure with each blood pressure reading. Assess skin turgor using the back of the client's hand. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.

ANS: A, C, D, E, F Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.) Lower sodium Higher calcium Lower potassium Higher phosphorus Higher calories

ANS: A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? Bring a list of all medications and what they are for. Keep the provider's phone number by the telephone. Make sure that all providers wash hands before entering the room. Write down the name of each caregiver who comes in the room.

ANS: AMedication reconciliation is a formal process in which the client's actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider's phone number nearby and documenting everyone who enters the room also do not guarantee safety.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? Client taking furosemide. Anxious client who has tachypnea. Client who is on fluid restrictions. Client who is constipated with abdominal pain.

ANS: B Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician? Swollen ankles in patient with compensated heart failure Positive Chvostek sign in patient with acute pancreatitis Dry mucous membranes in patient taking a new diuretic Constipation in patient who has advanced breast cancer

ANS: B Positive Chvostek sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek sign.

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? "All staff nurses are required to participate in quality improvement here." "Even being new, you can implement activities designed to improve care." "It's easy to identify what indicators would be used to measure quality." "You should ask to be assigned to the research and quality committee."

ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) Cleanse the perineum with an antibacterial soap. Use medicated wipes instead of toilet paper. Identify foods that decrease constipation. Apply a thin coat of aloe cream to the perineum. Gently pat the perineum dry after cleansing.

ANS: B, D, E To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? Weight gain of 2 pounds since last week Dry mucous membranes and skin tenting Urine output 8 mL/hr Blood pressure 98/58

ANS: C Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.

A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? Ask the hospitals there about standard nurse-client ratios. Choose the hospital that has the newest technology. Find a hospital that has achieved Magnet status. Work in a facility affiliated with a medical or nursing school.

ANS: C Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn't necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? Administer naloxone. Call the Rapid Response Team. Provide physical stimulation. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? Abdominal distention Nausea Electrolyte imbalance Obstipation

ANS: C The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes.

Nursing demonstrates dedication to improving public health through which avenue? Changing healthcare standards Legal regulations Scope of practice Technology

ANS: C Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing healthcare environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public. A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? A 36 year old who is prescribed long-term steroid therapy. A 55 year old who recently received intravenous fluids. A 76 year old who is cognitively impaired. An 83 year old with congestive heart failure.

ANS: COlder adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? Raise bed side rails due to potential decreased level of consciousness and confusion. Examine sacral area and patient's heels for skin breakdown due to potential edema. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. Institute fall precautions due to potential postural hypotension and weak leg muscles.

ANS: D Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? Auscultate after palpating. Avoid any type of palpation. Lightly palpate the RUQ first. Lightly palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question? Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr Furosemide (Lasix) 20 mg PO now Oxygen via face mask at 8 L/min KCl 20 mEq PO two times per day

ANS: A A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

The nurse is assessing a group of clients for their risk of kidney disease. Which racial/ethnic group is at the greatest risk as they age? Latino Americans African Americans Jewish Americans Asian Americans

ANS: B Older African Americans have a greater age-related decrease in glomerular filtration rate when compared to other racial-ethnic groups. In addition, blood flow decreases and sodium excretion is less effective in older hypertensive African Americans. These changes make this group most at risk for kidney disease.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) Cost-saving measures Nurse's expertise Client preferences Research findings Values of the client Plan-do-study-act model

ANS: B, C, D, EEBP consists of utilizing current evidence, the client's values and preferences, and the nurse's expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? Assesses the client's Chvostek and Trousseau sign. Keeps the client's room quiet and dimly lit. Moves the client carefully to avoid fracturing bones. Administers bisphosphonates as prescribed.

ANS: D Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

The new Director of Case Management assessed the need to improve the organization's patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? "The department will deliver reliable, collaborative, and compassionate discharge planning services to all patients." "The department will hold weekly meetings every Tuesday at 11:00 AM." "There will be implementation of a new uniform policy so staff can be readily identified." "Staff are encouraged to complain about difficult patients, families, and physicians."

ANS: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

Which action by the nurse working with a client best demonstrates respect for autonomy? Asks if the client has questions before signing a consent. Gives the client accurate information when questioned. Keeps the promises made to the client and family. Treats the client fairly compared to other clients.

ANS: A Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

Which nursing action best exemplifies clinical judgment? A nurse after performing an assessment seeks out additional information related to a finding. A nurse documents finding in the medical record in a timely manner. A nurse contacts the physician to provide the results of an imaging study for a patient. A nurse comforts a patient who is on hospice care.

ANS: A Clinical judgment represents a comprehensive well thought out series of action whereby the nurse incorporates assessment data in the context of norms and values. The nurse seeking out additional information to clarify a finding is demonstrating clinical judgment. A nurse who is documenting assessment data in the patients' medical record in a timely manner is being efficient. A nurse contacting the physician to provide results of an imaging test is demonstrating effective communication. A nurse comforting a patient who is on hospice care is demonstrating compassion.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? A 34 year old who is NPO and receiving rapid intravenous D5W infusions. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. A 67 year old who is experiencing pain and is prescribed ibuprofen. A 73 year old with tachycardia who is receiving digoxin.

ANS: A Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? Encourage the client and family to be active partners. Have the client monitor hand hygiene in caregivers. Offer the family the opportunity to stay with the client. Tell the client to always wear his or her armband

ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? Assess the client's respiratory rate, rhythm, and depth. Measure the client's pulse and blood pressure. Document findings and monitor the client. Call the health care primary health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? Assesses for cultural influences affecting health care. Ensures that all the client's basic needs are met. Tells the client and family about all upcoming tests. Thoroughly orients the client and family to the room.

ANS: A Showing respect for the client and family's preferences and needs is essential to ensure a holistic or "whole-person" approach to care. By assessing the effect of the client's culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care.

A nurse is reviewing decision-making theories. Which statement is accurate according to situational and contingency theory? a. The theory challenges the concept that one leadership style is always best.b. The theory supports employee feelings, morale, and feedback during the change process.c. Motivation through inspiration and recognition is the focus for transforming employee behavior.d. A leader is someone who possesses great intelligence and decision-making authority.

ANS: A Situational and contingency theory challenges the assumption that there is "one best way" to lead. A theory that supports employee feelings, morale, and feedback during the change process describes behavioral leadership. Motivation through inspiration and recognition is the focus for transforming employee behavior describes transformational leadership. A leader is someone who possesses great intelligence and decision-making authority describes Great Man or Trait theory.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? Call the Rapid Response Team. Document and continue to monitor. Notify the primary health care provider. Repeat the blood pressure in 15 minutes.

ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours' urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client's blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client.

A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) Consults with other disciplines on client care. Coordinates discharge planning for home safety. Participates in comprehensive client rounding. Routinely asks other disciplines about client progress. Shows the nursing care plans to other disciplines. Delegate tasks to unlicensed personnel appropriately.

ANS: A, B, C, D, F Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) Collaborating with an interprofessional team Implementing evidence-based care Providing family-focused care Routinely using informatics in practice Using quality improvement in client care Formalizing systems thinking when implementing care

ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report.

A nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.) Ensure adequate fluid intake. Leave the bathroom light on at night. Encourage use of the toilet every 6 hours. Delegate bladder training instructions to the assistive personnel (AP). Provide thorough perineal care after each voiding. Assess for urinary retention and urinary tract infection.

ANS: A, B, E, F The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse would not delegate any teaching to the AP, including bladder training instructions. The AP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) Test for skin tenting. Measure rate and character of pulse. Measure postural blood pressure and heart rate. Check Trousseau sign. Observe for flatness of neck veins when upright. Observe for flatness of neck veins when supine.

ANS: A, B, F ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

What are the main features of complexity science that are relevant to nursing leadership? (Select all that apply.) Focused on creating organizational change and looking at the whole versus individual parts Defined by efforts of leadership to mandate organizational change Autocratic in nature with a top-down structure for change Dependent on employees knowing what change is necessary and acting independently Non-linear and dynamic in nature, versus a static process

ANS: A, E Complexity science posits that interactions of the parts within a system are more important than the individual parts. Complexity science, however, recognizes that organizational processes are often non-linear and unpredictable. Through the dynamic interplay of negative and positive feedback an organization is able to make changes to keep abreast of the environmental context. The autocratic top-down decision making and mandates do not create a sustainable change. Being dependent on employees knowing what change is necessary and acting independently lacks interaction of leadership to stimulate change and adaptation among employees.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) Reports of palpitations Slow, shallow respirations Orthostatic hypotension Paralytic ileus Skeletal muscle weakness Tall, peaked T waves on ECG

ANS: A, E, F Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? Vomiting all day and not replacing any fluid Tumor that secretes excessive antidiuretic hormone (ADH) Tumor that secretes excessive aldosterone Tumor that destroyed the posterior pituitary gland

ANS: B ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? Attending to holistic client needs Ensuring client safety Not making medication errors Providing client-focused care

ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client's safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? Administer high-ceiling (loop) diuretics. Assess the client's lung sounds every 2 hours. Place a pressure-relieving overlay on the mattress. Weigh the client daily at the same time on the same scale.

ANS: B All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? Avoid embarrassing the client by asking questions. Don't make assumptions about his or her health needs. Most LGBTQ people do not want to share information. No differences exist in communicating with this population

ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? "I must drink a quart (liter) of water or other liquid each day." "I will weigh myself each morning before I eat or drink." "I will use a salt substitute when making and eating my meals." "I will not drink liquids after 6 p.m. so I won't have to get up at night."

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.

A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? "I would like you to order a different pain medication." "This client has allergies to morphine and codeine." "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." "This client had a vaginal hysterectomy 2 days ago."

ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, andRecommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated; the client's surgery 2 days ago would be considered background. Assessment would include an analysis of the client's problem; none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired.

To be an effective nursing leader today requires effective collaboration. Which model below best represents this process? The Nursing Manager of the observation unit was certain the psychology department would assist the unit with a motivational plan, so she did not request their assistance. The Nursing Manager of the observation unit worked with the psychology department and physical therapy to develop a motivational plan for patients on the unit. The Nursing Director of Behavioral Health Services followed the administrative directive to reduce services and refused to provide services for patients on other units. Frustrated by the trend of patients unwilling to work with therapy, the Unit Manager recommended that these patients be placed on another unit.

ANS: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? Encourage oral fluid intake. Connect the client to a cardiac monitor. Assess urinary output. Administer oral calcitonin.

ANS: B This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) Bilateral ankle edema Weaker leg muscles than usual Postural blood pressure and heart rate Positive Trousseau sign Flat neck veins when upright Decreased patellar reflexes

ANS: B, C, D Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) Hypomagnesemia—kidney failure Hyperkalemia—salt substitutes Hyponatremia—heart failure Hypernatremia—hyperaldosteronism Hypocalcemia—diarrhea Hypokalemia—loop diuretics

ANS: B, C, D, E, F Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) Sodium: 160 mEq/L (mmol/L): Overhydration Potassium: 5.4 mEq/L (mmol/L): Dehydration Osmolarity: 250 mOsm/L: Overhydration Hematocrit: 68%: Dehydration BUN: 39 mg/dL: Overhydration Magnesium: 0.8 mg/dL: Dehydration

ANS: B, C, D, F In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) Urine output of 25 mL/hr Serum potassium level of 5.4 mEq/L (5.4 mmol/L) Urine specific gravity of 1.02 g/mL Serum sodium level of 128 mEq/L (128 mmol/L) Blood osmolality of 250 mOsm/kg (250 mmol/kg)

ANS: B,E Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? Measure intake and output every 4 hours. Assess client further for fall risk. Increase the IV flow rate to 250 mL/hr. Place the client in a high-Fowler position.

ANS: BDehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? Prepare to administer patiromer by mouth. Provide a heart-healthy, low-potassium diet. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. Prepare the client for hemodialysis treatment.

ANS: C A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? Notifies the pharmacy of the IV potassium order. Assesses the client's IV site every hour during infusion. Sets the IV pump to deliver 30 mEq of potassium an hour. Double-checks the IV bag against the order with the precepting nurse.

ANS: C IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

The nursing unit director exhibits the definition of leadership in which of the following responses? By referring the concern to the Director of the department By correcting the concern with the patient directly and not communicating his/her actions to the staff By meeting with the staff to discuss the concern and identify solutions By telling the staff that they need to correct the situation by tomorrow and leaves the meeting

ANS: C Leadership is defined as an interactive process that provides needed guidance and direction which is present in the correct answer. The other choices do not involve an interactive process with staff to resolve the concern.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? "Have you spouse watch you for irritability and anxiety." "Notify the clinic if you notice muscle twitching." "Call your primary health care provider for diarrhea." "Bake or grill your meat rather than frying it."

ANS: C One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? Determining if the AP knew how to take blood pressure Double-checking the AP by taking another blood pressure Providing more appropriate supervision of the AP Taking the blood pressure instead of delegating the task

ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP.

The American Nurses Association (ANA) outlines expectations of nurse's self-care habits in which type of documentation? Nurse Practice Acts Board of Nursing Code of Ethics Hospital Facility Protocols

ANS: C The ANA focuses on the importance of nurses to develop their own personal self-care habits as part of their ethical code. This information is presented in the ANA Code of Ethics. Nurse Practice Acts define the scope of practice relative to the specific type of health professional. The Board of Nursing provides minimum competency requirements for specific types of health professionals and identifies licensing, academic and practice requirements. Hospital facilities provide policies and protocols related to members of the interdisciplinary healthcare team.

Which key element is included in the scope of professional practice identity? Adhering to a fixed level of practice Finding out ways to get done faster with assigned tasks as the key focus of care Maintaining professional boundaries Remaining at the level of practice upon graduating from nursing school

ANS: C The scope of professional identity includes five attributes, doing, and being, acting ethically, flourishing and changing identities. By maintaining professional boundaries, the nurse would be acting ethically. Adhering to a fixed level of practice would not be prudent for it would not allow the nurse to achieve attributes. Finding out ways to get done faster with assigned tasks would be in opposition to the attribute of "being" as the key focus is to do the right thing even when no one is looking. A nurse who remains at the level of practice upon graduation from nursing school would be in opposition to the attribute of flourishing.

The hospital must reduce the number of readmissions from 11% to 8% in the next year. Which of the following best represents the transformational leadership style in accomplishing this goal? The Director communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week. The organization charters three work teams to identify solutions for the top three causes for readmissions. These teams are given full authority to implement their solution. The Director of Quality develops a vision statement and action plan to achieve the goal. The director works directly with the involved departments to implement the action plan. The Chief Executive Officer (CEO) communicates the goal to the organizational directors and managers and states that they are entrusted to solve the problem.

ANS: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The Director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? Severe hemorrhage Diabetes insipidus Oliguric renal disease Adrenal insufficiency

ANS: C When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) Respiratory rate of 8 breaths/min Absent deep tendon reflexes Strong productive cough Active bowel sounds U waves present on the electrocardiogram (ECG)

ANS: C,D A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? Ask family members to speak quietly to keep the client calm. Assess urine color, amount, and specific gravity each day. Encourage the client to drink at least 1 L of fluids each shift. Dangle the client on the bedside before ambulating.

ANS: D An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? Slices of smoked ham with potato salad Bowl of tomato soup with a grilled cheese sandwich Salami and cheese on whole-wheat crackers Grilled chicken breast with glazed carrots

ANS: D Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

The nurse who is certified as a Critical Care Registered Nurse (CCRNTM) represents the unit on the organizational performance improvement team. This is an example of which type of leadership?a. Formalb. Unit c. Organizational d. Informal

ANS: D Informal leaders are recognized as leaders because of their capabilities and actions. Formal leaders are recognized because of the position they hold such as director or manager. Unit leadership refers to the leader of the particular unit. Organizational leadership refers to any leader within the organization.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? Increased respiratory rate from 12 to 22 breaths/min Decreased skin turgor on the client's posterior hand and forehead Increased urine specific gravity from 1.012 to 1.030 g/mL Decreased orthostatic changes when standing

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

The qualities of leadership, clinical expertise and judgment, mentorship, and lifelong learning would best describe which type of nurse? Administrator Certified nurse specialist Practitioner Professional

ANS: D The qualities listed are those of a professional nurse. The other options are all nurses who may have these qualities, but the focus of their title includes qualities not essential for the professional nurse. The administrator would have management qualities; the clinical nurse specialist would have specialty area knowledge; and the practitioner would meet legal requirements as a healthcare provider.

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? Development of ankle or sacral edema Increased skin tenting and dry mouth Postural hypotension and tachycardia Decreased level of consciousness

ANS: D Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

The clinical nurse leader needs to identify the staff who must go home due to low census. Which answer below describes a democratic style of decision making? The clinical nurse leader identifies the staff person with the most vacation and asks them to go home. The clinical nurse leader tells the last person to show up for their shift to go home. The clinical nurse leader decides not to send anyone home because it is too difficult to decide who should lose hours. The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer.

ANS: D Democratic leaders use a participatory style of decision making. In the other choices, the clinical nurse leader makes the decision independent of the staff.

A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best? Obtain daily weights of the client. Auscultate heart and breath sounds. Palpate the client's abdomen. Assess the client's diet history.

ANS: A Furosemide is a loop diuretic that helps reduce fluid overload and hypertension in patients with early stages of CKD. One kilogram of weight equals about 1 L of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds would be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse would check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effectiveness of the medication

A nurse contacts the primary health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A Normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Normal creatinine is 0.6 to 1.2 mg/dL (53.0 to 106.1 mcmol/L) (males) or 0.5 to 1.1 mg/dL (44.2 to 97.2 mcmol/L) (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This client's creatinine is normal, which suggests a nonrenal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse would recommend giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity are not appropriate.

A 70-kg adult client with chronic kidney disease (CKD) is on a 40-g protein diet. The patient has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would be of most concern to the nurse? Albumin level of 2.5 g/dL (3.63 mcmol/L) Phosphorus level of 5 mg/dL (1.62 mmol/L) Sodium level of 135 mEq/L (135 mmol/L) Potassium level of 5.5 mEq/L (5.5 mmol/L)

ANS: A Protein restriction is necessary with CKD due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the client's metabolic needs. The electrolyte values are not related to the protein-restricted diet.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? "It's a good thing I love orange and cherry gelatin." "My spouse will be here to drive me home." "I'll avoid ibuprofen for several days before the test." "I'll buy a case of clear Gatorade before the prep."

ANS: A The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How would the nurse respond? "Let's talk to the ostomy nurse to help you and your husband work through this." "You could try to wear longer lingerie that will better hide the ostomy appliance." "You should empty the pouch first so it will be less noticeable for your husband." "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse would collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse would not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

A nurse cares for a client who has a new colostomy. Which action would the nurse take? Empty the pouch frequently to remove excess gas collection. Change the ostomy pouch and barrier every morning. Allow the pouch to completely fill with stool prior to emptying it. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse would empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy barriers would be used to secure and seal the ostomy appliance; surgical tape would not be used.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) Cholangitis Pancreatitis Perforation Renal lithiasis Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

A nurse prepares a client for a percutaneous kidney biopsy. What actions should the nurse take prior to this procedure? (Select all that apply.) Keep the client NPO for 4 to 6 hours. Review coagulation study results. Maintain strict bedrest in a supine position. Assess for blood in the client's urine. Administer client's antihypertensive medications.

ANS: A, B, E Prior to a percutaneous kidney biopsy, the patient should be NPO for 4 to 6 hours. Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure. There is no need to keep the patient on bedrest or assess for blood in the client's urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) Serum potassium of 2.8 mEq/L (2.8 mmol/L) Loss of 15 lb (6.8 kg) without dieting Abdominal pain in upper quadrants Low-pitched bowel sounds Serum sodium of 121 mEq/L (121 mmol/L)

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic (normal range is 136 to 145 mEq/L [136 to 145 mmol/L]). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) Assist the client into a side-lying position. Use a rubber donut device when sitting up. Apply warm compresses three to four times a day. Instruct the client to wear boxer shorts. Place an absorbent dressing over the wound.

ANS: A, C, E The nurse would place an absorbent pad over the wound and apply warm compresses to the wound area. The nurse would also instruct the male client to wear jockey-type shorts for support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods, and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the use of air rings or rubber donut devices.

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine

ANS: B Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus. The other drugs do not affect intestinal activity.

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? Warm the dialysate solution in a microwave before instillation. Obtain a sample of the effluent and send to the laboratory. Flush the tubing with normal saline to maintain patency of the catheter. Check the peritoneal catheter for kinking and curling.

ANS: B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis.

The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? "This drug will make you very dry because it will decrease your diarrhea." "Be sure to take this drug with food and water to help manage constipation." "Avoid people who have infection as this drug will suppress your immune system." "Include high-fiber foods in your diet to help produce more solid stools."

ANS: B Lubiprostone is an oral laxative approved for women who have IBS with constipation (IBS-C). Water and food will also help to improve constipation. The drug is not used for clients who have diarrhea and does not affect the immune system. Although high-fiber foods are important for clients who have IBS, this client does not need fiber to help make stool more solid. Instead the fiber will help prevent constipation.

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? Ham sandwich on white bread, cup of applesauce, carbonated beverage Broiled chicken with brown rice, steamed broccoli, glass of apple juice Grilled cheese sandwich, small banana, cup of hot tea with lemon Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Patients with IBS are advised to eat a high-fiber diet. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. Clients should avoid alcohol, caffeine, and other gastric irritants.

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient's recent history? Pyelonephritis Dehydration Bladder cancer Kidney stones

ANS: B Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI related to urine flow obstruction.

A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse recognize as abnormal? pH of 5.6 Ketone bodies present Specific gravity of 1.020 Clear and yellow color

ANS: B Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally, no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings in a urinalysis.

The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) Stool consistency is similar to paste. Stoma becomes dark and dull. Skin around the stoma becomes excoriated. Skin around stoma becomes protruded. Stoma becomes retracted into the abdomen.

ANS: B, C, D, E A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. Therefore, both of those skin changes would need to be reported to the primary health care provider.

The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority complications would the nurse anticipate? (Select all that apply.) Dehydration Anemia Hypertension Dysrhythmias Heart failure

ANS: B, C, D, E The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) "I can continue to take antacids to relieve heartburn." "I need to ask for an antibiotic when scheduling a dental appointment." "I'll need to check my blood sugar often to prevent hypoglycemia." "The dose of my pain medication may have to be adjusted." "I should watch for bleeding when taking my anticoagulants."

ANS: B, C, D, E In discharge teaching, the nurse must emphasize that the client needs to have an antibiotic prophylactically before dental procedures to prevent infection. There may be a need for dose reduction in medications if the kidney is not excreting them properly (antacids with magnesium, antibiotics, antidiabetic drugs, insulin, opioids, and anticoagulants).

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) Weight gain Rectal bleeding Anemia Change in stool shape Electrolyte imbalances Abdominal discomfort

ANS: B, C, D, F The client who has CRC usually experiences unintentional weight loss and rectal bleeding, either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte imbalances are not common, but the client may note that the shape or consistency of stool has changed.

The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? Avoiding alcohol Quitting smoking Decreasing fluid intake Increasing dietary fiber .

ANS: C The major cause of hemorrhoid formation is constipation. Therefore, the nurse teaches the client ways to prevent constipation, which include increasing dietary fiber, increasing exercise and fluid intake, and avoiding straining when have a stool

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take? Ask if the client is experiencing pain in the right shoulder. Perform a rectal examination and assess for polyps. Recommend that the client have computed tomography. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or high-pitched bowel sounds, is indicative of bowel obstruction caused by the tumor. The nurse would contact the primary health care provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The nurse generalist is not quali fied to complete a rectal examination for polyps, and laxatives would not help this client.

After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client's understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) "I must change the ostomy appliance daily and as needed." "I will use warm water and a soft washcloth to clean around the stoma." "I might start bicycling and swimming again once my incision has healed." "I will make sure that I make lifestyle changes to prevent constipation." "I will be sure to have the recommended colonoscopies."

ANS: C, D, E The client has had a colon resection for early CRC and there is no indication that the client also had a colostomy. Follow up with recommended colonoscopies are essential to monitor for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps to decrease the risk for CRC recurrence. Exercise and other activities do not need to be restricted after the client has healed.

A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take? Obtain a urine culture and sensitivity. Place the client on restricted fluids. Assess the client's creatinine level. Increase the client's fluid intake.

ANS: D Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and presence of antidiuretic hormone. Increasing the client's fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed? "I will probably lose weight by cutting out potato chips." "I will cut out bacon with my eggs every morning." "My cooking style will change by not adding salt." "I am thrilled that I can continue to eat fast food."

ANS: D Fast-food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect?

High-pitched, rushing bowel sounds in the right lower quadrant

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? Low-fiber diet Skin protection Antibiotic administration Intravenous glucocorticoids

Skin protection Protecting the client's skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) Assess for proper placement of the tube every 4 hours or per agency policy. Flush the tube with water every hour to ensure patency. Secure the NG tube to the client's chin. Disconnect suction when auscultating bowel peristalsis. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse would frequently assess for NGT placement, patency, and output (drainage) every 4 hours or per agency policy. The nurse would also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse would disconnect suction. NGT irrigation may or may not be prescribed. If it is prescribed, hourly irrigation is not appropriate.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.) "Which food types cause an exacerbation of symptoms?" "Where is your pain or discomfort and what does it feel like?" "Have you lost a significant amount of weight lately?" "Are your stools soft, watery, and black?" "Do you often experience nausea and vomiting"

ANS: A,B The nurse would ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse would also assess the location, intensity, and quality of the patient's pain or discomfort. Clients who have IBS do not usually lose weight, have nausea and vomiting, or have stools that are black.

A nurse assesses a client recovering from a cystoscopy. Which assessment findings would alert the nurse to urgently contact the primary health care provider? (Select all that apply.) Decrease in urine output Tolerating oral fluids Prescription for metformin Blood clots present in the urine Burning sensation when urinating

ANS: A,D The nurse would monitor urine output and contact the primary health care provider if urine output decreases or becomes absent. The nurse would also assess for blood in the client's urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present. If bleeding is present, the nurse would urgently contact the primary health care provider. Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the patient received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the primary health care provider.

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client's history? "Have you been taking any aspirin, ibuprofen, or naproxen recently?" "Do you have anyone in your family with renal failure?" "Have you had a diet that is low in protein recently?" "Has a relative had a kidney transplant lately?"

ANS: AThere are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated, indicating some renal problems. A diet high in protein could be a factor in an increased BUN.

A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding? Alzheimer disease Hypertension Diabetes mellitus Viral hepatitis

ANS: B Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimer disease, diabetes mellitus, or viral hepatitis.

A client is started on continuous venovenous hemofiltration (CVVH). Which finding would require immediate action by the nurse? Potassium level of 5.5 mEq/L (5.5 mmol/L) Sodium level of 138 mEq/L (138 mmol/L) Blood pressure of 76/58 mm Hg Pulse rate of 88 beats/min

ANS: C Hypotension can be a problem with CVVH if replacement fluid does not provide enough volume to maintain blood pressure. The nurse needs to monitor for ongoing fluid and electrolyte replacement. The sodium level is normal and the potassium level is slightly elevated, which could be normal findings for someone with acute kidney injury. A pulse rate of 88 beats/min is within usual limits.

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? "I should leave the drainage bag above the level of my abdomen." "I could flush the tubing with normal saline if the flow stops." "I should take a stool softener every morning to avoid constipation." "My diet should have low fiber in it to prevent any irritation." .

ANS: C Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client. The drainage bag should be below the level of the abdomen. Flushing the tubing will not help with the flow. A diet high in fiber will also help with a constipation problem

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take? Contact the primary health care provider to recommend a low-sodium diet. Prepare to administer an intravenous diuretic. Encourage the client to drink more fluids. Obtain a suction device and implement seizure precautions.

ANS: C Normal urine osmolality ranges from 300 to 900 mOsm/kg (300 to 900 mmol/kg). This client's urine is more concentrated, indicating dehydration. The nurse would encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels. Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the client's dehydration or elevate the osmolality.

A nurse cares for a client with colorectal cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How would the nurse respond? "I have a good friend with a colostomy who would be willing to talk with you." "The ostomy nurse will be able to answer all of your questions." "I will make a referral to the United Ostomy Associations of America." "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including ostomates (specially trained visitors who also have ostomies). The nurse would not suggest that the client speak with a personal contact of the nurse. Although the ostomy nurse is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse would not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? Decreased calcium levels Increased phosphorus levels No adventitious sounds in the lungs Increased edema in the legs

ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance.

A nurse cares for a client who has a family history of colorectal cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How would the nurse respond? "If you eat a low-fat and low-fiber diet, your chances decrease significantly." "You are safe. This is an autosomal dominant disorder that skips generations." "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse would encourage the patient to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet to more high-fiber (not low-fiber) and preemptive chemotherapy may decrease the client's risk of colon cancer but will not prevent it.