Assessment RN VATI Adult Medical Surgical 2023, Exams of Nursing

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Assessment RN VATI Adult Medical Surgical 2016

1. Inspect the client's skin underneath the boot every 12 hr. The nurse should inspect the client’s skin underneath the boot every 8 hr for irritation, increased swelling, and skin breakdown. Remove the weights from the traction while repositioning the client in bed. MY ANSWER The nurse should not remove the weights from traction without a prescription from the provider. The purpose of the weight is to immobilize the hip prior to surgery and to decrease muscles spasms. Assess the client's circulation every 4 hr. The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreased perfusion and neurovascular changes. Request the client to perform dorsiflexion of the affected extremity every 1 hr. The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
2. Stop the blood transfusion immediately. A client who has type AB-positive blood is considered a universal recipient and can receive any ABO blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative donor. Prepare to administer antipyretics. Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a history of febrile reactions to prior transfusions or shows signs of chills or fever, there is no reason to administer antipyretics. Monitor the client for any adverse reactions. MY ANSWER

Although a client is considered a universal recipient because he can receive any ABO blood type, the nurse should continue to monitor the client for any adverse reactions, which is standard procedure for any blood transfusion. Transfuse the blood over 6 hr. The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration to reduce the risk of bacterial contamination of the blood.

3. Assess the client to determine the need for endotracheal suction every 4 hr. Evidence-based practice indicates the nurse should assess the client's need for endotracheal suction every 2 hr to ensure a clear airway. Check the ventilator settings every 12 hr. Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr to make sure the settings are at the correct levels. Keep the head of the client's bed elevated 30°. MY ANSWER The nurse should keep the head of the client's bed elevated at least 30° to promote increased lung expansion and to help prevent ventilator-associated pneumonia. Perform oral hygiene with chlorhexidine every 3 hr. Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine every 2 hr to help prevent ventilator-associated pneumonia from bacteria accumulating in the oral cavity and colonizing in the lower respiratory system.
4. High lipase A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected finding of hyponatremia or dehydration. Low urine specific gravity MY ANSWER

A client who has hyponatremia as a result of diuretic overuse will have a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity. Low hemoglobin A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level because of the difference in ratio between intravascular fluid and blood cells. High creatine kinase-MB (CK-MB) An elevated CK-MB level indicates a myocardial infarction has occurred and is not an expected finding of hyponatremia.

5. "I will adjust the rate of infusion based on my urinary output." The nurse should teach the client to monitor urinary output. However, the client should administer PN at a consistent rate prescribed by the provider. An infusion rate that is too rapid can cause hyperosmolar diuresis and hyperglycemia. A rate that is too slow can result in inadequate caloric and nutritional intake. "I will need to have a 60-milliliter syringe to administer my PN." The nurse should teach the client to use an electronic infusion device to prevent the accidental overload of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral tube feedings. "I will keep additional solution bags at room temperature." The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease the risk of bacterial growth. PN solution is an ideal environment for bacterial growth because of the high dextrose and fat content. "I will use aseptic technique when administering my PN." MY ANSWER The nurse should teach the client to use aseptic technique when connecting the infusion to the catheter hub to prevent microorganisms from entering the vascular system and causing a catheter-related bloodstream infection.

6. The stool will have a pasty texture. MY ANSWER The nurse should include in the teaching that stool with a pasty consistency is seen with a transverse colostomy. Over time, the drainage can become thicker as the body adapts to retain moisture. The stool will have a high volume of liquid. The nurse should include in the teaching that when peristalsis returns, a client can have an initial period of high-volume liquid stool output, up to 1,800 mL/day. Later, as the proximal small bowel adapts, stool volume should drop to about 800 mL/day. The stool will be solid and well-formed. The nurse should include in the teaching that solid stool is seen with a descending colostomy and is similar to stool that is evacuated from the rectum. Drainage from an ileostomy is not solid because it is not passing through the colon where a great deal of fluid is absorbed to form stool that is more solid in consistency. The stool will appear bloody with clots. The nurse should include in the teaching that the first drainage from an ileostomy can appear red in color but should not contain frank blood or clots and should quickly change to a greenish- yellow color.
7. Sudden, severe onset of hypertension Sudden, severe onset of hypertension is a late manifestation of increased intracranial pressure, which is a component of Cushing's triad. Therefore, there is another finding that is the first manifestation of a change in neurological status. Bradycardia Bradycardia is a late manifestation of increased intracranial pressure, which is a component of Cushing's triad. Therefore, there is another finding that is the first manifestation of the change in neurological status. Widened pulse pressure Widened pulse pressure is a late manifestation of increased intracranial pressure, which is a component of Cushing’s triad. Therefore, there is another finding that is the first manifestation

of a change in neurological status. Change in level of consciousness MY ANSWER When using the urgent vs nonurgent approach to client care, the nurse should determine the priority action is to assess a client's change in level of consciousness. An altered level of consciousness is the first manifestation of increased intracranial pressure.

9. Auscultate the client's abdomen for a bruit. The nurse should auscultate the client's abdomen for a bruit to assess for a renal artery injury or an abdominal aortic aneurysm. Check the client for fecal impaction. The nurse should monitor bowel movements and check the client for fecal impaction that can cause an increase in intra-abdominal pressure. Place the client in a supine position. MY ANSWER The nurse should elevate the head of the client's bed to reduce the risk for increased intra- abdominal pressure. Administer IV hypotonic fluids to the client. The nurse should infuse hypertonic fluids to reduce the risk for increased intra-abdominal pressure.
10. "I will eat a light breakfast the morning of the test." An OGTT is a fasting test, and the client should remain NPO for 12 hr prior to the test. "I should expect to drink a beverage containing glucose before the first blood draw." MY ANSWER The client should expect to drink a beverage containing glucose after the fasting blood draw of

the test. "I can expect to have my blood drawn at 15-minute intervals during the test." The client should expect to have her blood drawn at 30-min and hourly intervals. "I will report dizziness if it occurs during the test." The client should report dizziness that occurs during the test because this can indicate a drop in blood sugar and a need to obtain a blood glucose level. Transient reactions can include dizziness, sweating, weakness, and giddiness.

12. Oral temperature of 37.2° C (99° F) The nurse should expect a slight elevation of the client's temperature postoperatively. However, an increased temperature elevation or a spike can indicate an infection. Clear drainage on the dressings MY ANSWER The nurse should identify clear drainage on or around the dressing as an indication of a cerebral spinal leak and should report this finding to the provider immediately. Drain output 75 mL in 4 hr The nurse should expect the client to have no more than 125 mL of drain output in 4 hr. Decreased bowel sounds in all quadrants of the abdomen The nurse should expect decreased bowel sounds when caring for a client following a laminectomy due to anesthesia and pain medication. The nurse should continue to monitor the client to assess for a paralytic ileus.
13. Fever Fever and an elevated WBC count are manifestations of bacterial pericarditis. Atrial fibrillation Atrial fibrillation is a manifestation of acute pericarditis. Paradoxical pulse

Cardiac tamponade occurs from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or greater between expiration and inspiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately. Pericardial friction rub MY ANSWER Pericardial friction rub is a scratchy, high-pitched sound caused by inflamed pericardial tissue and is a manifestation of acute pericarditis.

14. Lovastatin is an HMG-CoA reductase inhibitor that can cause hepatotoxicity. Therefore, the nurse should teach the client to have liver function tests obtained prior to therapy and to monitor and report manifestations of liver injury, such as anorexia, jaundice, and abdominal pain. Statins increase the low density lipoprotein (LDL) receptors in the liver cells, which reduces LDL levels and can increase the risk for liver damage.
15. Place the infusion on hold and withdraw the blood culture from the central line. MY ANSWER The nurse should wait 1 hr to obtain the blood culture after the client has received the antibiotic infusion. Fluid and the antibiotic can interfere with the results of the blood culture. Withdraw the blood culture from the central line using a vacuum tube with a needle. The nurse should obtain the blood culture from the client's central line by using a needleless 3- mL syringe and then transfer into a vacuum tube. Using a needleless system decreases the risk of infection to the IV site and also prevents needle stick injury. Cleanse the connections with 70% alcohol. The nurse should cleanse the connections prior to drawing blood with a vigorous action for a 15- second scrub using 70% alcohol in order to remove bacteria, fungi, and viruses. Flush the client's central line using a 5-mL syringe. The nurse should use a 10-mL to 20-mL syringe to flush a central line after obtaining the blood culture to prevent clotting of the catheter.

17. "I will perform self-catheterization once a day." A client should perform intermittent catheterization at least two or three times daily to prevent infection from urinary retention. "I will watch for cloudy urine." MY ANSWER A client who has a SCI might not be aware of infection because he cannot feel dysuria, urgency, or back pain and must rely on other manifestations, such as cloudy and foul-smelling urine. "I will drink 1 liter of fluid every day." The client should have a fluid intake of 2 to 3 L to maintain kidney perfusion and ensure adequate urine output. "I will remove the condom catheter for cleaning every 48 hours." A client should remove the condom catheter every evening to clean the penis and then dry thoroughly to reduce the risk for infection.
18. Uses fingers to remove loose tissue The nurse should use scissors and forceps to remove loose tissue from the burn while performing hydrotherapy. Removing nonviable tissue promotes wound healing. Opens small blisters to expose air The nurse should avoid opening small blisters while performing hydrotherapy. This allows the blisters to work as a protective barrier and promotes wound healing. Washes the burn with a mild detergent The nurse should wash the burn with a mild and unscented detergent and rinse thoroughly while performing hydrotherapy to decrease bacterial growth. Perfumed detergents can irritate the skin and can interfere with wound healing. Applies wet-to-dry dressing MY ANSWER

The nurse should not apply a wet-to-dry dressing on a burn injury because it does not promote wound healing. The nurse should dress burn wounds using synthetic dressings, biological dressings, or artificial skin to promote wound healing.

20. Brushing her hair using her left hand The client should not attempt to brush her hair on the first postoperative day because this action can increase stress on the incision. However, the client's goal is mobility, not stretching or straining, on the first postoperative day. Flexing and extending the fingers of her left hand MY ANSWER The client should begin flexing and extending the fingers of her left hand in the PACU as soon as she can follow instructions. "Walking" up a wall with both hands The client should begin range-of-motion exercises on the second postoperative day, which includes "walking" up a wall with both hands. Squeezing and releasing a ball in her left hand The client should begin to squeeze and release a ball in her left hand by the first postoperative day. The client can regain arm function on the affected side after a mastectomy and axillary lymph node dissection by performing a progressive series of arm and shoulder exercises to prevent contractures, maintain tone, and improve blood and lymph circulation
21. Reposition the client frequently is correct. This is part of standard postoperative care for any client to prevent cardiovascular, pulmonary, and integumentary complications of reduced mobility. Secure the drainage tube to the client's thigh is correct. Secure the catheter to the client's thigh to prevent excessive traction on the catheter balloon and to minimize postoperative bleeding.

Monitor the client's temperature every 4 hr is correct. This is part of standard postoperative care for any client to detect for early manifestations. Administer antispasmodics for bladder spasms is correct. Bladder spasms result from irritation of the bladder mucosa and can be relieved by applying warm compresses to the lower abdomen. If the spasms persist, the client might need antispasmodic medications. Restrict fluid intake to 1,500 mL/day is incorrect. Increase fluid intake to 2 to 2.5 L daily to increase urinary clarity and prevent dysuria.

24. "Administer this medication into your leg muscle." The client should administer enoxaparin into the subcutaneous tissue and not the muscle. The abdomen is commonly used as the injection site. "Expel the excess air in the syringe before you administer the medication." MY ANSWER The client should not expel excess air from the syringe. The air in the syringe ensures that the client is receiving the accurate dose of medication and can also decrease bruising at the injection site. "Insert the entire needle into your skin to administer medication completely." The nurse should advise the client to insert the entire needle into the skin to administer the medication completely. A small needle is used so that the medication does not go into the muscle. "Take ibuprofen for fever following administration of this medication." The nurse should advise the client to avoid taking over-the-counter products that contain aspirin or NSAIDs to prevent bleeding.

First-degree heart block A first-degree atrioventricular (AV) block has a regular rhythm where the atrial impulses are slower than normal when moving through the AV node into the ventricles. The heart rate is between 60/min and 100/min with clear P waves. Atrial fibrillation In atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm. Complete heart block MY ANSWER A complete heart block has regular rhythm with a heart rate usually between 30/min and 40/min. P waves are clear but have no relation with the QRS complexes. Ventricular tachycardia Ventricular tachycardia is a rapid, regular rhythm with a heart rate greater than 140/min. Although no P waves are visible in ventricular tachycardia, they can be sustained or nonsustained and can last for 15 to 30 seconds.

26. "Take the medication on an empty stomach." The nurse should instruct the client to take colesevelam, a lipid-lowering agent, with meals to increase absorption. "Increase fiber in your diet." Colesevelam is a lipid-lowering agent that can cause constipation, bloating, and indigestion. Therefore, the nurse should instruct the client to increase fluid and fiber intake. "Discard the oral suspension if it is cloudy after mixing." The nurse should instruct the client to expect the oral suspension to be cloudy because colesevelam powder is a lipid-lowering agent and is not water soluble. "Avoid drinking grapefruit juice." MY ANSWER

Colesevelam is a lipid-lowering agent that does not interact with grapefruit juice. However, the client should avoid drinking grapefruit juice when taking statins because grapefruit juice can reduce the metabolism of statins, which can cause toxicity.

27. Increase intake of high-fiber foods. Increasing intake of high-fiber foods does not decrease the adverse effect of dry mouth. Chew sugarless gum. Benztropine is an anticholinergic medication that blocks cholinergic receptors, which can cause dry mouth. The nurse should recommend the client chew sugarless gum to stimulate saliva production. Moisten the mouth with lemon-glycerin swabs. MY ANSWER Lemon-glycerin swabs cause mucosal irritation from drying and can break down the enamel on the client's teeth. Soft, foamy mouth swabs are a recommended choice for the client to use for dry mouth. Rinse the mouth with nystatin. Nystatin is used for the treatment of candida, an oral fungal infection, but it is not indicated for the treatment of dry mouth.
28. A defined area of reddened but intact skin A client who has a stage 1 pressure ulcer can have reddened skin in the earliest stage, which can feel either firm or boggy, and warm or cool. A shallow crater involving the epidermis A client who has a stage 2 ulcers will have partial-thickness skin loss involving the epidermis, dermis, or both. The area might have a small shallow crater, or can appear as an abrasion or blister. Reddened area that does not blanch

MY ANSWER

A client who has a stage 1 pressure ulcer will have an area of skin that is red, blue, or purplish in color and does not blanch to external pressure. Leakage of cloudy fluid from abraded skin area A client who has a stage 3 pressure ulcer can have exudate and purulent drainage, indicating necrosis to the subcutaneous tissues.

29. Instruct the client to lift no more than 6.8 kg (15 lb) when at home. The nurse should instruct the client to lift objects no heavier than 2.3 kg (5 lb) for several weeks following surgery to prevent reinjuring the lower back. Turn the client by log rolling with a turning sheet. MY ANSWER The nurse should turn the client by log rolling with a turning sheet to keep the client's back straight and to prevent back spasms from occurring. Inform the client to shower on the second postoperative day. The nurse should inform the client to shower on the third or fourth postoperative day to ensure the healing of the incisional line. Remove sterile adhesive strips before discharge. The nurse should leave the sterile adhesive strips on until the provider removes them or until the strips fall off.

Expiratory rhonchi The nurse should expect a client who has a pulmonary embolus to have crackles, wheezes, or a pleural friction rub when auscultating breath sounds. Petechiae over the lower extremities

The nurse should expect a client who has a pulmonary embolus to have petechiae over the chest and axillae. Hemoptysis The nurse should expect a client who has a pulmonary embolus to have hemoptysis, which is an indication of a pulmonary infarction. Flattened neck veins MY ANSWER The nurse should expect a client who has a pulmonary embolus to have distended neck veins due to decreased tissue perfusion.

33. A pearly, waxy nodule A client who has basal cell carcinoma will have a nodular lesion with well-defined borders that has a pearly or waxy appearance, caused from overexposure to the sun on the face, neck, or arms. An irregular border on a variegated-colored lesion A client who has melanoma will have a lesion that has irregular-shaped borders and variegated colors of red, white, and blue tones, generally found on the upper back or lower legs. A firm, nodular, crusty, or ulcerated lesion MY ANSWER A client who has squamous cell carcinoma will have a lesion that is firm, nodular, and crusty with an ulcerated center, caused from sun exposure, chronic irritation, burns, or irradiation to the skin. A weeping vesicle A client who has herpes zoster will have weeping, blister-type lesions.
34. A BUN of 24 mg/dL is greater than the expected reference range, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the

client for increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate transplant rejection.

BUN 16 mg/dL A BUN level of 16 mg/dL is within the expected reference range. An elevated BUN level can indicate a risk for fluid volume deficit. Urine output of 40 mL every hour for 3 hr MY ANSWER Urine output of 40 mL every hour for 3 hr is within the expected reference range. A client needs to produce a minimum of 400 mL to 600 mL of urine in 24 hr to excrete toxic waste. Hct 42% An Hct of 42% is within the expected reference range. Hematocrit above the expected reference range can indicate a risk for fluid volume deficit. Surgical drain output of 300 mL during an 8-hr shift. A client who had lumbar spinal surgery should not have more than 250 mL in 8 hr from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate the client is at risk for fluid volume deficit.

43. Cimetidine is correct. Cimetidine is an H2 histamine receptor antagonist that relieves heartburn and acid indigestion. It can increase the effects of warfarin. Echinacea is incorrect. Echinacea is a supplement that a client takes to improve immunity and has no known interaction with warfarin. Aspirin is correct. Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin.

Dextromethorphan is incorrect. Dextromethorphan is a cough suppressant and has no known interaction with warfarin. Naproxen is correct. Naproxen is a NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin.

44. Place the client on droplet precautions. The nurse should implement droplet precautions to reduce the risk for disease transmission because bacterial meningitis is transmitted by droplets. Perform a cranial nerve assessment on the client every 2 hr. The nurse should perform neurological checks and vital signs every 2 to 4 hr to monitor for increased intracranial pressure, which can indicate hydrocephalus. Assist the client out of bed three times per day. A client who has bacterial meningitis should remain on bed rest with the head of bed elevated 30° to reduce the risk for increased intracranial pressure. Therefore, the nurse should clarify this prescription with the provider. Assess the client's weight daily. MY ANSWER The nurse should assess the client's weight to monitor for fluid retention.
45. S3 gallop S3 gallop is an expected finding of left-sided heart failure due to pulmonary congestion and increased left ventricular pressure that causes a decrease in cardiac output and poor tissue perfusion. Weak peripheral pulses MY ANSWER

Weak peripheral pulses are an expected finding of left-sided heart failure due to decreased cardiac output. Increased abdominal girth Increased abdominal girth is an expected finding of right-sided heart failure due to systemic congestion and an enlarged liver and spleen. Systemic congestion can lead to fluid retention and increased pressure in the venous system, which can manifest with edema in the lower extremities. Wheezing Wheezing is an expected finding of left-sided heart failure due to pulmonary congestion and systolic dysfunction.

46. Dependent edema The nurse should identify that dependent edema is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure build up in the venous system. Jugular distension The nurse should identify that jugular distension is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure build up in the venous system. Weight gain The nurse should identify that weight gain is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure build up in the venous system. Frothy sputum MY ANSWER The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left- sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.

Distended jugular veins Distended jugular veins can occur when a client receives a blood product too rapidly. This is a manifestation of circulatory overload. Report of low back pain MY ANSWER Report of low back pain is a manifestation of a hemolytic transfusion reaction, often from incompatible blood, which can progress into circulatory collapse. Report of itching A client who is having an allergic transfusion reaction can have itching, urticaria, and bronchospasms that can progress into anaphylaxis. Temperature 37.8° C (100° F) An increase in temperature of 0.5° C or 1° F is a manifestation of a febrile or bacterial transfusion reaction.

Place the affected leg in external rotation. The nurse should maintain the affected extremity in neutral position to prevent dislocation. Manifestations of a dislocation of the hip include the affected leg rotates in an inward position, the client has sudden severe pain, and the surgical extremity is shorter. Encourage the client to use the incentive spirometer every shift. The nurse should encourage the client to cough, deep breathe, and use the incentive spirometer every 2 hr to prevent pneumonia and atelectasis, which is the collapse of alveoli. Atelectasis can lead to poor oxygen exchange and pneumonia. Instruct the client to lean forward when rising from a chair. MY ANSWER To prevent dislocation of the hip, the client should not flex more than 90º at any time. Leaning forward when rising from a chair flexes the hip more than 90º.

Maintain abduction of the affected extremity. The nurse should ensure the affected extremity is in a position of abduction to prevent dislocation. Abduction of the affected extremity is maintained by placing an abductor pillow or several pillows between the client's legs when in bed.

53. "I will increase my consumption of foods high in potassium." Cephalosporins do not increase the excretion of potassium, so it is not necessary for the client to increase consumption of potassium. "I will apply lotion to my skin if I feel any itching." A common adverse effect of cephalosporins is a hypersensitivity reaction. Itching of the skin can indicate a hypersensitivity reaction, and the client should report this finding to the provider. "I will avoid sun exposure while taking this medication." MY ANSWER Cephalosporins are not known to cause photosensitivity. However, ciprofloxacin and other fluoroquinolones have an adverse effect of photosensitivity. Photosensitivity can cause the client to have an increased risk of developing a sunburn when the skin is exposed to direct sunlight. "I will keep the medication refrigerated." The nurse should instruct the client to refrigerate oral cephalosporin suspensions to maintain full strength until the regimen is completed.
54. Elevated WBC count is correct. A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000/mm3 to 18,000/mm3. If the WBC count is greater than 20,000/mm3 it can indicate a perforated appendix. Elevated amylase level is incorrect. Amylase levels increase with pancreatitis but not with acute appendicitis.

Rebound tenderness is correct. A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client's abdomen. Constipation is correct. Constipation is a manifestation of appendicitis. Due to the possibility of perforation, the nurse should not give laxatives to a client who has abdominal pain, nausea, and low-grade fever. Anorexia is correct. A client who has acute appendicitis experiences nausea and vomiting.

55. Hyperkalemia MY ANSWER A client who has hyperkalemia can have ECG changes such as premature ventricular contractions, ventricular fibrillation, and widened QRS. This is a dangerous electrolyte disturbance because it can cause cardiac dysrhythmias, which can be life-threatening. Hypocalcemia A client who has hypocalcemia can have abdominal cramps, paresthesia of the fingertips, muscle cramps, tremors, irritability, confusion, and psychosis. A client who has acute kidney failure might develop hypocalcemia. However, the client is not showing manifestations of this electrolyte imbalance at this time. Hypernatremia A client who has hypernatremia can have tachycardia, hypertension, edema, thirst, muscle rigidity and weakness, CNS irritability, restlessness, and agitation. A client who has acute kidney failure can have typical or dilutional hyponatremia, depending on fluid balance. Hypophosphatemia A client who has hypophosphatemia can have hypotension, anorexia, nausea, vomiting, malaise, fatigue, seizures, chest pain, muscle weakness, mental confusion, lethargy, and coma. A client who has acute kidney failure can have hyperphosphatemia, not hypophosphatemia.

56. Anticoagulant therapy MY ANSWER The nurse should advise the client to use chondroitin with glucosamine with caution while on anticoagulant therapy because this supplement can increase the risk for bleeding. The nurse should advise the client to monitor for manifestations of bleeding, such as bruising and black, tarry stools. Hypotension A client who has hypertension, not hypotension, should not take glucosamine. History of hypoglycemia Glucosamine can cause hyperglycemia, not hypoglycemia. Allergy to eggs A client who has a shellfish allergy should use glucosamine with caution because glucosamine is made from the exoskeletons of shellfish.
57. Glucose The nurse should test the cerebrospinal fluid for glucose. However, evidence-based practice indicates that another assessment is more reliable because glucose also is present in blood. The client's nasal discharge is serosanguineous, so the glucose in the blood will give a positive result whether or not the discharge contains cerebrospinal fluid. Halo sign MY ANSWER According to evidence-based practice, the nurse should check the nasal discharge for a halo or ring sign to determine if the drainage is cerebrospinal fluid. To check for the halo or ring sign, the nurse should let the draining fluid collect onto gauze or a tissue. Within a few minutes, the blood in the drainage will coalesce into the center and a yellowish ring will encircle the blood if cerebrospinal fluid is present. Yellow drainage The nurse should assess the color of the cerebrospinal fluid. However, evidence-based practice indicates that another assessment is more reliable because nasal secretions can also appear yellow in color. Cerebrospinal fluid is usually clear and colorless but can appear yellow in color

from hemolysis of RBCs. Yellow drainage does not confirm nor rule out the presence of cerebrospinal fluid in the client's nasal discharge. WBCs The nurse should test the cerebrospinal fluid for WBCs. However, evidence-based practice indicates that another assessment is more reliable. WBCs are present in cerebrospinal fluid and are present in blood. The client's nasal discharge is serosanguineous, so the WBCs in the blood will give a positive result whether or not the discharge contains cerebrospinal fluid.

58. "I will secure electric cords under carpeting.” The nurse should instruct the client not to place electric cords under carpeting because it can increase the risk of a fire or tripping over uneven carpet. "I should purchase a new tub mat." The older adult client should purchase a skid-proof mat or apply strips in the tub or shower to provide a gripping surface for wet feet to reduce the risk for falls. "I will wear shoes with leather soles in my house.” The nurse should instruct the client to wear shoes or slippers with rubber soles to prevent slipping and reduce the risk for falls. "I will get some rubber-backed throw rugs for my vinyl floors." MY ANSWER Older adult clients can experience a decrease in muscle mass as aging occurs, causing a decrease in leg strength and less leg lift. Therefore, the client can trip over the edges of rubber-backed throw rugs, increasing the risk for falls. Rugs also can become bunched, wrinkled, or displaced, adding to the risk for tripping and falling.
59. "Keep a cell phone 6 inches away from your pacemaker while in use." The nurse should instruct the client to keep a cell phone 15.2 cm (6 in) away from the pacemaker while in use to prevent interference with the function of the generator. "Avoid showering for the first 2 weeks following surgery."

Following surgery, the client may take a bath or shower as long as careful attention is given to the pacemaker site. "Avoid heavy lifting for 1 week following insertion." The client should avoid heavy lifting for several weeks following insertion to allow the pacemaker to settle in place. "Stand at least 3 feet away while using a microwave." MY ANSWER The client does not need to stand 3 feet away while using a microwave because microwaves are protected by shielding. Therefore, this safety measure is not needed.

60. Administer stool softeners as prescribed. The nurse should administer stool softeners to a client who has portal hypertension to reduce straining, which increases vascular pressure and can precipitate bleeding esophageal varices. Esophageal varices are dilated, bulging esophageal veins that overfill as a result of portal hypertension and can easily hemorrhage. Place the client in semi- or high-Fowler's position. MY ANSWER Positioning the client this way facilitates lung expansion by reducing pressure on the diaphragm. Clients who have liver disease often have an ineffective breathing pattern related to ascites and liver enlargement. However, positioning the client this way does not prevent esophageal varices. Offer the client a low-carbohydrate diet. Clients who have liver disorders are usually fatigued due to malnutrition and the disease process itself. A well-balanced, high-carbohydrate, moderate-fat, high-protein, and low-sodium diet is recommended for a client who has cirrhosis of the liver, but it does not prevent esophageal varices. Infuse sodium chloride IV as prescribed. Clients who have portal hypertension from long-term liver cirrhosis should restrict sodium intake to prevent an increase in ascites fluid. Sodium chloride IV is not administered to prevent esophageal varices.

MY ANSWER

Fixed pupils is incorrect. Fixed pupils can indicate overmedication or brain injury. Increased heart rate is correct. Increased heart rate can occur with acute pain due to activation of the sympathetic nervous system and increased amounts of circulating catecholamines. Restlessness is correct. Clients who are unable to communicate often become restless in the presence of pain. Increased respiratory rate is correct. Increased respiratory rate can occur with acute pain due to activation of the sympathetic nervous system and increased need for oxygen. Increased blood pressure is correct. Increased blood pressure can occur with acute pain due to activation of the sympathetic nervous system.

63. Increased pigmentation Topical glucocorticoid therapy can cause the adverse effect of hypopigmentation. Localized hair loss Long-term glucocorticoid therapy can cause hypertrichosis, or excessive hair growth, especially on the facial area. Thinning of the skin MY ANSWER Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid preparations. The client should only apply the ointment to dry patches of the skin because topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning of the skin.

Increased sensitivity to the sun The nurse should instruct the client to avoid excessive sun exposure when taking topical fluticasone, but triamcinolone ointment does not cause photosensitivity.

The nurse should first apply clean gloves to prevent the transmission of bacteria and maintain the use of standard precautions. Swabbing the wound in a zig-zag manner ensures adequate quantity of specimen, and placing the swab into the culture container preserves the specimen for evaluation. The nurse should finally label the specimen with client information, date, and time to ensure results are reported correctly.

Administer the medication no faster than 100 mg/min. MY ANSWER The nurse should plan to administer phenytoin no faster than 50 mg/min to reduce the risk of cardiovascular collapse. Flush the IV catheter with sterile water before and after administering the medication. The nurse should plan to flush the IV catheter with 0.9% sodium chloride before and after administering the medication to prevent precipitate from developing when it comes in contact with incompatible solutions, such as D5W. Plan to add the medication to the existing IV solution. The nurse should add phenytoin to no more than 50 mL of 0.9% sodium chloride to reduce the risk of precipitation and to ensure the medication is infused within 1 hr. Use a particulate final filter between the IV catheter and the tubing. The nurse should plan to place a particulate micron in-line filter between the IV catheter and tubing before administering phenytoin via intermittent bolus to reduce the risk of precipitate entering the client's bloodstream.