MED SURG FINAL EXAMS GALEN COLLEGE OF NURSING TEST BANK WITH ACTUAL CORRECT QUESTIONS AN, Exams of Nursing

Download MED SURG FINAL EXAMS GALEN COLLEGE OF NURSING TEST BANK WITH ACTUAL CORRECT QUESTIONS AN and more Exams Nursing in PDF only on Docsity! Page | 1 MED SURG FINAL EXAMS GALEN COLLEGE OF NURSING TEST BANK WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS BY EXPERTS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+ |LATEST UPDATE A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. What should the nurse request in SBAR communication with the health care provider? Portable chest X-ray Antibiotic therapy Intubation and mechanical ventilation Arterial blood gasses Antibiotic therapy Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. With the symptoms of infection, antibiotic therapy would be recommended. Nothing in the question demonstrates a need for chest X-ray, intubation, or ABGs. A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used. Apply an occlusive dressing over the puncture site Tape the dressing on three sides Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. Assess the client's respiratory status. Assess vital signs and await further medical orders A chest tube is a flexible, hollow tube placed through the chest wall and in to the pleural space. The chest tube is able to relieve trapped air and fluid. If a chest tube is dislodged and comes out, the nurse would immediately apply an occlusive dressing such as Vaseline gauze (many times kept in the client's room). The dressing is taped on three sides. The first action always focuses on the client. The nurse would direct another licensed nurse to immediately notify the health care provider. The nurse would then assess the respiratory status. The nurse would obtain vital signs and await further orders. Page | 2 After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when noting which of the following? Select all that apply. Fluctuations in the water-seal chamber occur when the client breathes. Crepitus forms at the chest tube insertion site. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber. Fluctuations in the water-seal chamber occur when the client breathes. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber. Fluctuations in the water-seal compartment (or tidal movements) indicate normal function of the system as the pressure in the tubing changes with the client's respirations. There also should be intermittent bubbling in the water-seal chamber, indicating that air is being removed from the pleural cavity by the system. Gentle bubbling in the suction control chamber indicates that the proper suction level has been reached. Drainage is expected to collect in the drainage chamber after a lobectomy. Crepitus indicates that air is leaking into the subcutaneous tissues. The physician should be notified of this finding. The nurse is planning care for a child with a pneumothorax. The nurse adds the nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube" to the care plan. When writing the care plan, what should the nurse be sure to include as interventions? Keep dry gauze at the bedside Ensure a pair of hemostats are at the bedside Monitor pulse oximetry readings Assess lungs as directed by the physician or as the client's condition warrants Maintain chest tube bottle in an upright position and below the level of the chest Ensure a pair of hemostats are at the bedside Monitor pulse oximetry readings Assess lungs as directed by the physician or as the client's condition warrants Maintain chest tube bottle in an upright position and below the level of the chest If the tube becomes dislodged from the child's chest, the nurse must apply Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural space. A pair of hemostats should be kept at the bedside to clamp the tube should it become dislodged from the drainage container. Pulse oximetry and lung assessments help ensure proper placement of the chest tube. To maintain proper drainage, the bottle must be kept upright and below the level of the chest. The nurse has received a change-of-shift report. The nurse should assess which client first? a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 Page | 5 Call for assistance and then cover the wound with a sterile dressing. Call for assistance and cover the insertion site with clean, dry gauze. Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. Instructing the client to exhale forces air out and allows the space to be covered before a sucking chest wound occurs. The wound needs to be covered with an occlusive dressing to prevent leak of air. Breathing slowly will still allow air re-entry. The nurse is caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which items will the nurse obtain to respond appropriately to accidental disconnection of the chest tube from the drainage device? An unopened bottle of sterile water A Heimlich valve Two rubber-tipped clamps A spare chest tube insertion kit An unopened bottle of sterile water Keep bottle of sterial saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water. When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply. Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Maintain wall suction at a low setting so there is intermittent bubbling. Position the client in the prone or supine position to permit optimal drainage. Ensure all connections are securely taped. Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Ensure all connections are securely taped. It is important to ensure that chest tube connections are secure so there are no air leaks. In addition, postoperative considerations include checking the chest tube dressing. The drainage would also be measured at the end of each shift. These are primary considerations postoperatively after a lobectomy. Wall suction must be continuously bubbling to ensure there is active suction in the pleural space. The client needs to be in the Fowler's position to promote effective breathing. Prone or supine would not be appropriate. A firefighter is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the firefighter reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Page | 6 Select all that apply. Monitor for fever. Prepare the chest for chest tube insertion. Auscultate the lungs for adventitious breath sounds. Assess for increased pulse rate. Monitor for increased anxiety levels. Auscultate the lungs for adventitious breath sounds. Monitor for increased anxiety levels. Assess for increased pulse rate. More than half of all clients with pulmonary involvement following inhalation injury do not immediately demonstrate pulmonary signs. Any client with possible inhalation injury must be observed for at least 24 hours for possible respiratory complications. Maintaining increased oxygen saturation levels is essential, especially following a carbon monoxide inhalation injury, to prevent the development of carboxyhemoglobin, which competes with oxygen for available hemoglobin. The client does not typically develop a fever with inhalation injury, but may progress to acute respiratory syndrome with bilateral lung infiltrates, cardiac involvement with tachycardia, and increasing anxiety due to oxygen starvation. A chest tube is not indicated. A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should: administer pain medication and delay client activity. tell the client why lung expansion is important. arrange a care schedule that includes rest periods. teach the client how to use an incentive spirometer. administer pain medication and delay client activity. Administering pain medication and delaying any activity until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and acts as a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort. A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A chest tube A tracheostomy Page | 7 An endotracheal tube A feeding tube A tracheostomy In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction. A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: lobar pneumonia. empyema. Pneumocystis carinii pneumonia. infected chest tube wound site. empyema. Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage. The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? Remove the chest tube. Document the finding. Contact the Rapid Response Team. Remind the client to remain stationary in bed to stop the bubbling. Document the finding. Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate. A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse? Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Position in Fowler's position to assist in breathing and give oxygen as ordered. Page | 10 possible by sitting the client up, and then provide supplemental oxygen to minimize impending hypoxia. It is also important to have suction equipment readily available because the client may choke on oral secretions due to the pulmonary edema. After performing these interventions, the nurse would notify the physician and anticipate orders for administration of a diuretic (such as furosemide) and insertion of an indwelling urinary catheter to measure eventual output. The nurse is performing routine tracheostomy care. Which step would be appropriate for the nurse to include in the performance of the procedure? Remove the inner cannula every 2 hours for cleaning. Secure the tracheostomy ties with a square knot. Use cut gauze under the neck plate to protect the skin. Suction the inner cannula on completion of the procedure. Secure the tracheostomy ties with a square knot. When performing tracheostomy care, it is important that the tracheostomy ties be securely tied to prevent dislodgment of the tube. It is not necessary to remove the inner cannula every 2 hours for cleaning. Routine cleaning is usually performed every 8 hours. The nurse should use precut tracheostomy dressings under the neck plate to protect the skin surrounding the stoma. Cutting and using a gauze dressing can cause loose gauze fibers to enter the airway. The inner cannula should be suctioned before cleaning, not afterward. A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in discharge teaching? Select all that apply. Provide humidity at home. Follow a bland diet. Learn how to suction. Have communication rehabilitation with a speech pathologist Attend a smoking cessation program. Provide humidity at home. Learn how to suction. Have communication rehabilitation with a speech pathologist Attend a smoking cessation program. Home care for a client with a total laryngectomy should include a high-humidity environment, laryngectomy tube care and suctioning, speech rehabilitation, and smoking cessation. The client is not restricted to a bland diet. A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order from first to last should the nurse take the actions? All options must be used. Clear the area around the client. Loosen clothing around the client's neck. Turn the client on his or her side. Page | 11 Suction the airway. The goal of care for a client who is having a seizure is to prevent respiratory arrest and aspiration. The nurse should first clear the area around the client. Next, the nurse should loosen clothing around the client's neck and turn the client on the side. As needed, the nurse can then suction the airway and administer oxygen. The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? Ensure that suction apparatus is set up at the bedside. Pad the patient's bed rails. Maintain bed rest whenever possible. Provide several small meals each day. Ensure that suction apparatus is set up at the bedside. Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand. Bed rest should be generally be minimized, not maximized, and there is no need to pad the patient's bed rails or to provide multiple small meals. The nurse is suctioning the tracheostomy of a child. The nurse should: insert the catheter with the suction port of the catheter closed. keep the catheter straight as it is removed from the tracheostomy tube. use clean technique while suctioning. insert the catheter slightly beyond the end of the tracheostomy tube. insert the catheter slightly beyond the end of the tracheostomy tube. To prevent damage to the carina, the catheter should only be inserted just slightly beyond the end of the tracheostomy tube. The catheter should be inserted with the suction port open, then removed while turning the catheter with the suction port closed. The catheter should be rotated as it is removed to better clear secretions from the airway. In acute care settings, tracheostomy suctioning in children is an aseptic procedure. In some circumstances, it can be a clean procedure in the home. A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. Provide frequent mouth care. Apply mineral oil to the lips. Page | 12 Arrange for suctioning to remove mucus. Change the client's position every two hours. .Assist the client to a lateral position. Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the lips of the client to overcome dryness caused by oxygen therapy. The client's position should be changed every 2 hours to promote comfort and circulation. When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds? 5 seconds 10 seconds 15 seconds 20 seconds 15 seconds Suctioning the respiratory tract for prolonged periods depletes the client's oxygen supply and causes hypoxia. It is recommended that each suctioning period not exceed 15 seconds. A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? Call the physician. Remove the malfunctioning cuff. Add more air to the cuff. Suction the client, withdraw residual air from the cuff, and reinflate it. Suction the client, withdraw residual air from the cuff, and reinflate it. After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture. A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: Page | 15 states (e.g., delirium). In the latter stages of irreversible dementia, reality orientation is less successful and often causes agitated or angry responses. At this latter point, validation therapy (Feil, 2002) may be an effective strategy. In addition, the nurse should avoid criticizing, correcting, or arguing with the client. The nurse is caring for a client who has late stage dementia. Prior to administering oral medications, what is the appropriate nursing action? Change medication route to intramuscular. Mix the drug with pudding. Request that the provider obtain a speech therapist's evaluation. Administer medication with water to drink. Request that the provider obtain a speech therapist's evaluation. To prevent aspiration, the nurse will ask the provider to consult with a speech therapist for evaluation of dysphagia. The nurse cannot convert order for medications to a different route. Water or pudding may increase the risk for aspiration if a dysphagia evaluation has not been completed. The nurse should be cautious and closely monitor clients receiving donepezil (Aricept) with which medical condition? (Select all that apply.) Hyperthyroidism Seizure disorder Renal disease Asthma GI bleeding Seizure disorder Renal disease Asthma GI bleeding Cholinesterase inhibitors, like donepezil (Aricept), are used cautiously in clients with renal or hepatic disease, bladder obstruction, seizure disorder, sick sinus syndrome, GI bleeding, history of ulcer disease, and asthma. What are common skin reactions that a nurse should warn a client about when they are initiated on antipsychotic therapy? (Select all that apply.) Urticaria Stevens-Johnson syndrome Photosensitivity Hyperpigmentation Toxic epidermal necrolysis Urticaria Photosensitivity Page | 16 Urticaria and photosensitivity are common skin reactions that a nurse should warn a client about when they are initiated on antipsychotic therapy. A nurse should monitor a client taking donepezil (Aricept) for which adverse effects? (Select all that apply.) Anorexia Dizziness Headache Constipation Bradycardia Anorexia Dizziness Headache Generalized adverse reactions to cholinesterase inhibitors like donepezil (Aricept) include: anorexia, nausea, vomiting, diarrhea, dizziness, and headache and therefore should be monitored for by the nurse. At night, an elderly client with senile dementia wanders into other clients' rooms, awakening them. What is the best nursing intervention for dealing with this client's insomnia and nocturnal roaming? Administer a benzodiazepine at bedtime as ordered. Administer a low-dose antipsychotic at bedtime as ordered. Administer a barbiturate at bedtime as ordered. Lock the client's door at bedtime. Administer a low-dose antipsychotic at bedtime as ordered. In elderly clients, low-dose antipsychotics are preferred for sedation and improvement in thinking. Benzodiazepines are usually avoided because of the risk of addiction, cardiovascular complications, and impaired motor coordination. Barbiturates also are avoided because they may cause delirium, confusion, excitement, and addiction. Locking the door is inappropriate and would violate the client's rights. The nurse is caring for older adult in an assisted care facility. What information about the older adult client should the nurse consider when caring for this population of client? (Select all that apply.) Some clients with dementia may experience sundowning syndrome and safety is a priority. Delirium experience by a client is a permanent state of confusion Observe for symptoms of depression since many clients go undiagnosed. All older adults experience delirium when they are hospitalized Medication should be closely monitored for polypharmacy A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. Some clients with dementia may experience sundowning syndrome and safety is a priority. Observe for symptoms of depression since many clients go undiagnosed. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. Page | 17 Several of the statements listed are true statements. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark. Depression is a prolonged or extreme state of sadness occurring in many older adults. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. There were three statements that were not true. First, delirium is not a permanent state of confusion occurring in older adulthood. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Polypharmacy does not look at the number of pharmacies used to obtain prescriptions but the amount of drugs prescribed by health care providers for a variety of medical conditions. Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Complicated regimens need careful review to minimize risks and complications and maximize benefits. A client with dementia of Alzheimer's disease is prescribed rivastigmine. Which instruction should the nurse include in the teaching plan for the client? Select all that apply. Avoid food with spices and seasonings. Immediately report occurrence of adverse reactions. Keep all appointments with primary health care provider. Do not take any nonprescription drug. Avoid taking the drug on an empty stomach. Immediately report occurrence of adverse reactions. Keep all appointments with primary health care provider. Do not take any nonprescription drug. The nurse should instruct the client to immediately report any occurrence of adverse reactions, such as nausea, vomiting, diarrhea, anorexia, dyspepsia, fatigue, and insomnia; keep all appointments with the primary health care provider, and not take any nonprescription drugs. The nurse need not ask the client to avoid food with spices and seasonings or avoid taking the drug on an empty stomach; the use of rivastigmine tartrate is not affected by these factors. A client is admitted with a diagnosis of dementia becomes agitated, violent, and has bizarre thoughts. The nurse is reviewing the client's medication record. Which ordered medication would be expected to reduce agitation? tacrine ergoloid diazepam risperidone risperidone Risperidone is ordered for severe agitation and has a rapid response. Ergoloid and tacrine stabilize and may improve the cognitive functioning of clients with dementia. Diazepam is an antianxiety agent that would not have the desired effect on the severe agitation, violence, and bizarre thoughts. Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice? Select all that apply. A nurse forgets to put the side rails up on a crib and the toddler falls out. A nurse does not report a change in client condition in a timely manner. Page | 20 The client reports having delusions The client exhibits confusion The client has difficulty finding words The client reports an inability to perform complex tasks The client has difficulty finding words The nurse suspects the client may have mild dementia as the client is reporting difficulty in finding words during conversation, along with anxiety over the client's forgetfulnesss. Confusion and the inability to perform complex tasks are possible indicators of moderate dementia. Delusions are typically experienced by client's suffering from severe dementia. The nurse is caring for a client admitted to a medical surgical unit. Which of the following situations would indicate a professional nurse's boundary violation? Select all that apply. Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Being concerned about a client's welfare and seeking ways to protect them Having well-intentioned behaviors that detract from achievable health outcomes for clients Reminding a client who has dementia that certain sexual touch behaviors are not acceptable Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Having well-intentioned behaviors that detract from achievable health outcomes for clients Professional boundaries focus on the provision of professional care that assists clients in achieving health outcomes. When the professional nurse becomes overinvolved in care, then it may affect those outcomes. Sharing a personal experience with a client that is very similar to the situation the client is experiencing is not appropriate because it places the focus on the nurse, not the client. Speaking to a client's family without permission violates confidentiality. Being concerned about a client's welfare and seeking ways to protect them and reminding a client who has dementia that certain sexual touch behaviors are not acceptable would not compromise professional boundaries. A nurse should be able to differentiate between the typical and atypical antipsychotics. Which are classified as typical antipsychotics? (Select all that apply.) Lithium (Eskalith) Aripiprazole (Abilify) Chlorpromazine (Thorazine) Haloperidol (Haldol) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Haloperidol (Haldol) Fluphenazine (Prolixin) Page | 21 The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply. asking questions repeatedly stable mood socially inappropriate behavior wandering irritabilty asking questions repeatedly socially inappropriate behavior wandering irritabilty Behavioral findings associated with dementia include: asking questions repeatedly, emotional lability, socially inappropriate behavior, wandering and irritability. The nurse expects psychiatric hospitalization for which of the clients diagnosed with schizoaffective disorder experiencing delusional thoughts? Select all that apply. A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression A 39-year-old person who reports minor side effects from the current medication A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression Hospitalization may be required during acute psychotic episodes or when suicidal ideations are present. This structured environment protects the client from self-harm (e.g., suicidal, assaultive, financial, legal, vocational, or social). Emergency care also is needed during periods of symptom exacerbation. Psychosis, mood disturbance, and medication-related adverse effects account for most emergency situations. The nurse would expect psychiatric hospitalization for the following clients with schizoaffective disorder experiencing delusional thoughts: a 76-year-old person whose symptoms are acute in nature, a 25-year-old person who is having a first delusional experience, a 45-year-old person who was arrested for assaulting a policeman, and a 30-year-old person who also has a diagnosis of depression. A nursing student is learning about drugs that affect the central nervous system. The student knows that some clien'ts with schizophrenia are given which drugs? Select all that apply. antipsychotic drugs antidepressants Page | 22 neuroleptics antispasmodics antipsychotic drugs neuroleptics Drugs used to treat psychotic disorders are called neuroleptics and antipsychotics. Antidepressants are a different classification used for mood disorders. Antispasmodics are used to treat muscle spasms. A client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects? Guanethidine Droperidol Lithium carbonate Alcohol Droperidol When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. Guanethidine, lithium carbonate, and alcohol do not increase the risk of extrapyramidal effects. A newly admitted client with an acute exacerbation of psychotic symptoms of schizophrenia is having trouble deciding whether to live in a group home or a supervised apartment. Based on the client's current cognitive functioning, which activity is most appropriate for the nurse to ask the client to do initially? List the pros and cons of each housing option. Choose between apple and orange juice for breakfast. Identify why the client cannot live in an unsupervised apartment. Decide which staff member the client would like to have today. Choose between apple and orange juice for breakfast. The client is in an acute psychotic state and cannot process complex decisions or explain complex situations. Therefore, the nurse would focus on decision making involving simple choices. Listing the pros and cons of each housing option and identifying why the client cannot live in an unsupervised apartment involve complex decision-making skills. Deciding which staff member to have today is a difficult and threatening decision for a client who is psychotic. Assessment of violence potential is an important part of nursing care on the inpatient unit. Which is an indicator that the client with schizophrenia may be at high risk for violence while in the hospital? The client has never used drugs or alcohol. The client assaulted an officer prior to admission. The client reports feeling that everyone on the unit is "out to get me." The client is suspicious of the nursing staff. Page | 25 A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. Monitor serum creatinine and blood urea nitrogen levels. Administer a sedative. Keep the head of the bed flat. Administer humidified oxygen. Auscultate the lungs. Monitor serum creatinine and blood urea nitrogen levels. Administer humidified oxygen. Auscultate the lungs. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis. What is the key sign of onset of acute respiratory distress syndrome? Tachypnea Stridor Hypoxemia Chest pain Hypoxemia The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status. A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) pH Bicarbonate (HCO3-) Partial pressure of arterial oxygen (PaO2) In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed. Page | 26 Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? septic shock chronic obstructive pulmonary disease asthma heart failure septic shock The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS. The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention? Partial pressure of arterial oxygen (PaO2) of 69 mm Hg Partial pressure of arterial carbon dioxide (PaCO2) of 51 mm Hg pH of 7.29 Bicarbonate (HCO3-)of 28 mEq/L Partial pressure of arterial oxygen (PaO2) of 69 mm Hg In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed. An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply. Epiglottitis Acute respiratory distress syndrome Pneumonia Pulmonary edema Cardiac tamponade Acute respiratory distress syndrome Pneumonia Pulmonary edema Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on Page | 27 auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade. A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia GERD kidney failure disseminated intravascular coagulation acute respiratory distress syndrome When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction. The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect. A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Page | 30 Allow connection to a manual resuscitation bag Prevent aspiration into the lungs Establish an airway for ventilation Allow connection to a manual resuscitation bag Prevent aspiration into the lungs Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions. The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does the nurse display? Fidelity Autonomy Beneficence Nonmaleficence Beneficence Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities. Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition. Nonmaleficence is the duty to do no harm to the client. A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply. The client will need ventilator support. The client will be unable to independently ambulate. The client will have no control of the bladder. The client will need assistance with feeding. The client will be unable to speak. The client will be cognitively impaired. The client will be unable to independently ambulate. The client will have no control of the bladder. The client with a spinal cord transection (complete tear) at the thoracic 4 location will be a paraplegic with no control of the body below mid chest. The client will need assistance to ambulate (wheelchair) and assistance with urination. The client will be able to breathe independently, speak, feed themselves and have normal cognitive function. Which ventilator mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate? Page | 31 IMV SIMV Assist control Pressure support Assist-control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing. Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Intermittent mandatory ventilation (IMV) Assist control Synchronized intermittent mandatory ventilation (SIMV) Pressure support IMV IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing. Which finding would indicate a decrease in pressure with mechanical ventilation? Kinked tubing Increase in compliance Decrease in lung compliance Plugged airway tube Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure. The nurse is caring for a client who is on a ventilator. The nurse is bathing the client and talking to him as she is carrying out care, as well as telling the client what is going to happen next. The nurse speaks to the client in a soothing manner. The nurse is acting in which role? Select all that apply. Caregiver Page | 32 Decision-maker Communicator Educator Client advocate Caregiver Communicator Educator The nurse is fulfilling the role of caregiver by providing the care and speaking to the client in a soothing manner. The nurse is also acting as a communicator by talking to the client, even if the client can't respond. The nurse is also acting as an educator by informing the client of the care that will be performed. The nurse is not assisting in making any decisions or speaking on behalf of the client. The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the client's mouth with chlorhexidine daily Maintaining the client in a high Fowler's position Ensuring that the client remains sedated while intubated Turning and repositioning the client every 4 hours Cleaning the client's mouth with chlorhexidine daily The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion. The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply. Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. Assess for decreased body temperature. Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. If the child begins to exhibit signs of poor oxygenation, perform a quick assessment. Auscultate the lungs Page | 35 Maintain a calm, nonthreatening environment. Explain relevant aspects of chemotherapy. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Provide distractions for the client during periods of stress. Teach the stages of grieving to the client. Maintain a calm, nonthreatening environment. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. During periods of acute stress, interventions that help the client regain control will help master this new threat. Providing a calm, nonthreatening environment and encouraging verbalization of concerns will help the client face the unknown. Relaxation techniques have a physiologic and psychological effect in calming the client, which in turn allows further exploration of thoughts and feelings as well as problem solving. The ability to learn is limited during extreme stress, so teaching the client about grief and chemotherapy would not be effective at this stage. Providing distractions would be ineffective at this point in the grief process. A client was recently in a motor vehicle accident, which resulted in an amputation of the right leg. The client is withdrawn, doesn't want to get out of bed, and has been crying a lot. What behaviors is the client demonstrating? Anticipatory grief Bereavement Mourning Anger Bereavement The client is exhibiting a symptom of bereavement which includes emotional, physical, social, and cognitive responses. The nurse is discussing end-of-life decisions with a patient who has terminal cancer. Which statements describe the patient's options? (Select all that apply.) Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. In a living will, a patient appoints an agent that he or she trusts to make decisions if he or she becomes incapacitated. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. The status of advance directives varies from state to state. Nurses are legally responsible for arranging for a durable power of attorney for all terminal patients. Legally, all attempts must be made by the health care team to resuscitate a terminal patient. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. Page | 36 The status of advance directives varies from state to state. Advance directives, including living wills, helps the patient to make decisions concerning their end-of-life care. Appointing an agent for care involves identifying a durable power of attorney for healthcare, which is the responsibility of the patient, family, or significant others. If a patient has advance directives, resuscitation is not warranted. Which are considered physiological signs the nurse expects to observe in a grieving individual? Select all that apply. Hypersomnia Weight gain Indigestion Palpitations Lack of energy Indigestion Palpitations Lack of energy The client may experience indigestion, palpitations, and lack of energy due to grief. While experiencing grief, the client may sleep more than usual throughout the day rather than during one specific time of day. Grief may suppress the client's appetite resulting in weight loss and not weight gain. A nurse is conducting a program for a local community support group about grieving. The nurse would describe grief as fulfilling which function? Select all that apply. allowing the outer reality of loss to become internally accepted altering the emotional attachment to that which was lost permitting the bereaved person to become unattached to others preparing the client for the loss without warning allowing the person to avoid the experience of the loss more fully allowing the outer reality of loss to become internally accepted altering the emotional attachment to that which was lost Grief has several important functions: to make the outer reality of the loss into an internally accepted reality; to alter the emotional attachment to the lost person or object; and to make it possible for the bereaved person to become attached to other people or objects. Grief does not prepare the client for the loss nor does it allow the person to avoid the experience the loss more fully. Grief is a necessary and normal reaction to loss. The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply. The nurse and physician are on call 24 hours, every day of the week. Medications to treat cancer are provided. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included. Page | 37 The nurse and physician are on call 24 hours, every day of the week. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included. Among the many available services, hospice services include on-call nurses and physicians (24 hours per day, 7 days per week), counselors, pain management techniques, and homemaker services. Patients receiving hospice care are not actively being treated for cancer, but rather are receiving palliative care. A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? Petechiae Butterfly rash Jaundice Skin sloughing Butterfly rash An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Patients with SLE do not typically experience jaundice or skin sloughing. The nurse is completing a health history review of a client who has received long term medical steroid therapy for Lupus. Which client data does the nurse recognize as potentially linked to the steroid use? Select all that apply. A 16 pound (7.3 kilogram) weight loss 3 infections over the course of the year Routine symptoms of nausea An increase in client blood pressure Acne noted on the forehead, cheeks, and back 3 infections over the course of the year Acne noted on the forehead, cheeks, and back Suppression of the immune system occurs when a client receives long term steroid therapy making the client more susceptible to infections. Acne is present related to oily skin and also the overproduction of the acne bacterium, Propionibacterium acnes. Also, changes in metabolism occur leading to weight gain, not weight loss. Nausea and hypertension are not commonly seen with steroid use. A client, with systemic lupus erythematosus (SLE) has been on corticosteroid therapy for the last 2 years. The nurse should assess for which of the following? Select all that apply. Hypoglycemia and cognitive changes Skeletal muscle atrophy and osteoporosis Hyponatremia and hypokalemia Hyperpigmentation of the skin and itching Hyperglycemia and fluid retention Page | 40 Corticosteroids Nonsteroidal anti-inflammatories Antimalarials are specific to SLE; antirheumatics are specific to JIA. Antipyretics are not typically used for either disorder. A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. "My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I can't continue to wash dishes and do my cleaning because of this problem." "I don't need to report any other skin problems with my fingers or hands to my practitioner." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem." "My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem." Raynaud's phenomenon causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when the client is exposed to cold or stress. It is caused by episodic vasospasm in the small peripheral arteries and arterioles and can affect the feet as well as the hands. The phenomenon is commonly associated with connective tissue diseases such as lupus and may be alleviated by calcium channel blockers or adrenergic blockers. It does not limit the client's ability to function, although the symptoms are bothersome. Keeping the hands warm and learning to manage stressful situations effectively reduces the frequency of episodes. The disorder can progress to skin ulcerations and even gangrene in some clients, so all skin changes should be reported to the practitioner promptly. A client has been rehospitalized with a severe exacerbation of lupus. Her husband approaches the nurse and says, "My wife is scaring me. She says she does not want to live with this illness anymore. Our kids are grown, and she feels useless as a mother and a wife." Which statements are the most appropriate responses to the husband? Select all that apply. "I will have a talk with your wife to see if she is suicidal." "You need to be strong and optimistic when you are with her." "I am glad you shared this with me. I can imagine that this is scary for you." "I am sure she will feel differently when we get this episode under control." "We can talk about what you can say to her that may help." "I will have a talk with your wife to see if she is suicidal." "I am glad you shared this with me. I can imagine that this is scary for you." "We can talk about what you can say to her that may help." Page | 41 Suicide is a risk with chronic illnesses. The husband needs validation of his feelings and support, as well as suggestions for helping his wife with her concerns. Telling him to be strong and optimistic ignores the client's needs. It is false to assume that the client will no longer be suicidal when the lupus is under control. A client with systemic lupus erythematosus reports palpitations, dyspnea on exertion, and leg swelling. The client's symptoms may indicate: cardiomyopathy. pericarditis. thrombophlebitis. Buerger's disease. Cardiomyopathy Dilated cardiomyopathy is accompanied by dyspnea on exertion and when lying down. The client experiences fatigue and leg swelling and may also have palpitations and chest pain. When a client's medical history includes disorders that are bacterial or viral in origin, a family history of early cardiac deaths, or any of several other conditions that correlate with heart involvement, the possibility of cardiomyopathy is considered. Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack), or develops after cardiac surgery. Clients with thrombophlebitis often complain of discomfort in the affected extremity. With Buerger's disease, the client notes that one or both feet are always cold and may report numbness, burning, and tingling in some areas of the feet. A 22-year-old woman has received an organ transplant and is on cyclosporine therapy. The nurse will encourage her to avoid crowds and limit social activities while on the medication due to: increased sedation. episodes of extreme dizziness. increased risk of infections. frequent migraine headaches. increased risk of infections. Cyclosporine therapy suppresses the immune system to limit immune reactions directed toward the new organ; however, the suppression also causes a generalized increased susceptibility to infection. Patients taking cyclosporine should avoid exposure to infections by avoiding crowds and promptly reporting injuries or signs of infection. The drug is not known to cause sedation, extreme dizziness, or migraine headaches. A client with end-stage liver disease is scheduled to undergo a liver transplant. The client tells the nurse, "I am worried that my body will reject the liver." Which statement is the nurse's best response to the client? "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." "You would not be scheduled for a transplant if there was a concern about rejection." "The problem of rejection is not as common in liver transplants as in other organ transplants." "It is easier to get a good tissue match with liver transplants than with other types of transplants." "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Page | 42 Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5- year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the client's anxiety. A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. Which initial assessment data would the nurse anticipate? Select all that apply. Decreased respiratory rate Dyspnea on exertion Barrel chest Shortened expiratory phase Clubbed fingers and toes Fever Dyspnea on exertion Barrel chest Clubbed fingers and toes COPD is one of the most common lung diseases making it difficult to breathe. Severity of the illness varies. Typical findings for clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usually tachypneic with a prolonged expiratory phase. Fever is not associated with COPD, unless an infection is also present. A 53-year-old female hospital patient has received a kidney transplant following renal failure secondary to hypertension. As part of the teaching while she was on the organ wait list, she was made aware that she would need to take anti-rejection drugs for the rest of her life. Which aspect of the immune system underlies this necessity? The lack of identifiable major histocompatibility complex (MHC) molecules will stimulate the innate immune response. Donor organ antibodies will be identified as foreign and stimulate an immune response. Anti-rejection drugs will stimulate the production of familiar MHC molecules. MHC molecules will never develop in the cells of the donor organ and effector cells will be continually stimulated. MHC molecules will never develop in the cells of the donor organ and effector cells will be continually stimulated. The lack of familiar MHC molecules will stimulate an immune response by effector cells in the absence of anti-rejection drugs. An innate immune response is not central to the response, but rather the Page | 45 The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Lung cancer Bronchitis Tracheobronchitis ARDS Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis. The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Disseminated intravascular coagulation (DIC) Septicemia Stevens-Johnson syndrome from the administration of antibiotics DIC Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites. A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Handwashing can prevent the spread of the disease to others. The importance of compliance with antibiotic therapy Signs and symptoms of complications, such as meningitis and septicemia The likely need for surgery to prevent scarring of the conjunctiva Handwashing can prevent the spread of the disease to others. Page | 46 The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Patients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis. Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply. Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body A client with peptic ulcer disease Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa Client who is having shoulder surgery Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa A client with severe burns, as well as a client who has had gastric surgery, would both be a candidate for total parenteral nutrition. TPN is designed for clients who are severely malnourished who will not be able to eat for a long period. A client with anorexia nervosa would also be an appropriate candidate for TPN. A client who has peptic ulcer disease will be able to eat after initiation of a medication regimen. A client who is having shoulder surgery will likely be able to return to a normal diet within a short time frame. The nurse is preparing an assessment guide for the emergency department staff regarding assessment of clients are admitted with burn injuries. What should the nurse be sure to include in the assessment guide for primary emergency assessment of burns? Airway assessment Depth of the burn/s Presence of edema Percentage of body burned Pulse strength Airway assessment Presence of edema Pulse strength The primary survey includes evaluation of the child's airway, breathing, and circulation. The secondary survey focuses on evaluation of the burns and other injuries. The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Vomiting Burns Diarrhea Dehydration Trauma Page | 47 Burns Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus. A child with 20% second- and third-degree burns is admitted to the burn center. The child weighs 44 lbs (20 kg). The nurse has started an IV infusion of lactated Ringer solution and inserted an indwelling catheter. Which of the findings indicate that the child is going into shock? Select all that apply. Urinary output is 25 ml/hr. Specific gravity is within normal limits. Pain is 7 on a pain scale of 1 to 10. Heart rate is elevated. Blood pressure is dropping. Heart rate is elevated. Blood pressure is dropping. The child is observed for shock that can occur following a severe burn. Shock is noted by the increasing heart rate and dropping blood pressure. This child has an adequate urine output (more than 1 ml/kg body weight) and the specific gravity is within normal range. Pain is expected and is not an indicator of shock. The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. Base-bicarbonate deficit Elevated hematocrit level Potassium deficit Sodium deficit Magnesium deficit Base-bicarbonate deficit Elevated hematocrit level Sodium deficit At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit). A client who has used IV heroin every day for the past 10 years says, "I don't have a drug problem. I can quit whenever I want." Which defense mechanism is being used by the client? Page | 50 unconscious. Which medication would the nurse most likely expect to administer? Naloxone Naltrexone Bupropion Varenicline Naloxone Naloxone, an opioid antagonist, is given to reverse respiratory depression, sedation, and hypertension. Naltrexone is used to treat alcohol dependence. Bupropion and varenicline are used to promote smoking cessation. High doses of alcohol produce which effect? Vomiting Decreased muscle tension Increased inhibitions Calmness Vomiting An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression. A nursing student is aware that which accounts for more deaths, illnesses, and disabilities across the life span than any other preventable condition? Motor vehicle accidents Substance abuse disorders Falls Mood disorders Substance abuse disorders Substance abuse disorders across the life span account for more deaths, illnesses, and disabilities than any other preventable health condition. Before his hospitalization, a client needed increasingly larger doses of barbiturates to achieve the same euphoric effect he initially realized from their use. From this information, the nurse develops a plan of care that takes into account that the client is likely suffering from problem? tolerance addiction abuse dependence tolerance Tolerance for a drug occurs when a client requires increasingly larger doses to obtain the desired effect. Therefore, the plan of care would address the client's state of tolerance. The term addiction refers to psychological and physiologic symptoms indicating that an individual cannot control his or her use of psychoactive substances. This term has been replaced with the term dependence. Abuse refers to the excessive use of a substance that differs from societal norms. Drug dependence occurs when the client must take a usual or increasing amount of the drug to prevent the onset of abstinence symptoms, Page | 51 cannot keep drug intake under control, and continues to use even though physical, social, and emotional processes are compromised. A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycodone. Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given that prescription by her health care provider (HCP). "She just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic? "I understand that your mother may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken." "It may be appropriate for your mother to be referred to a pain management program." "Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over time." "I can hear how upset you are. You sound very concerned about your mother." "I can hear how upset you are. You sound very concerned about your mother." Acknowledging the client's son's feelings is the most therapeutic intervention because he is not likely to hear the nurse's information until his anger and other feelings are addressed and subside. Then it is important to acknowledge that oxycodone, especially in older clients, can interfere with remembering how many pills were taken. It is common for clients with chronic pain to inadvertently overuse or become addicted to pain medications. Pain management programs help clients to withdraw from the offending medication and start on a multifaceted system for controlling the pain. A nurse is teaching a group of families who have members experiencing addiction about this problem. Which of the following, if stated by the families, indicates that the teaching was successful? Addiction results from a defect in the person's character. A single factor is usually responsible for development of addiction. Addiction is not a result of a person having moral faults. Addiction rarely results in the person experiencing relapse. Addiction is not a result of a person having moral faults. Addiction is not a defect in character or a moral fault. It results from a combination of factors, such as values, beliefs, family and personal norms, spiritual convictions, and conditions of the current social environment. Even with treatment, relapse, which is considered part of the illness process, can occur. A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's father states that he's going to have his son declared legally incompetent. Which response by the nurse is most therapeutic? "Your son is ill and can't make decisions about himself and his safety right now, but this situation is temporary." "You don't have the right to declare your son incompetent. He has rights, too." "I'll help you contact the hospital legal representative for help with the paperwork." Page | 52 "If you become your son's guardian, you'll be responsible for his finances and for paying for his treatment." "Your son is ill and can't make decisions about himself and his safety right now, but this situation is temporary." The client is temporarily unable to make decisions about his health care and safety. After receiving emergency care and treatment, he'll probably be able to safely manage his daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting his civil rights. A guardian doesn't assume financial responsibility. A client has completed treatment for an addiction to prescription pain medications. As part of the client's therapy, the family participates in a family therapy program. Which reason would best explain the need for a family system approach to therapy? The family needs to focus on helping the client until equilibrium is regained. The dynamics of the entire family have and will continue to shift to accommodate a change. The family has unresolved issues toward the client. The family needs to learn signs of relapse if the client begins taking pills again. The dynamics of the entire family have and will continue to shift to accommodate a change. When a family system is affected in some way, the dynamics of that family shift to a new balance. The family reorganizes or begins functioning at a different level than it did prior to the change, disturbance, or intervention. A change in one member affects all members. A client is admitted to the emergency department for intoxication with alcohol. The client has an unsteady gait, myopathy, and neuropathy and cannot remember past or recent events. When treated with thiamine, the client's symptoms greatly improve. Which condition was the client likely experiencing? Scurvy Wernicke-Korsakoff syndrome Alcohol dependence with memory impairment Alcoholic dementia Wernicke-Korsakoff syndrome Wernicke-Korsakoff syndrome is the coexistence of Wernicke's encephalopathy and Korsakoff's psychosis. Wernicke's encephalopathy is characterized by ataxia, nystagmus, ophthalmoplegia, and mental status changes. Korsakoff's psychosis involves gait disturbances, short-term memory loss, disorientation, delirium, confabulation, and neuropathy. Page | 55 disorders, recently they have been viewed as operating within the context of "vulnerability" factors in susceptible people. A client loses control and throws two chairs toward another client. What should the nurse do next? Ask the client to go to the quiet area and talk about the behavior. Administer an oral PRN tranquilizer, and prepare for a show of determination. Process the incident with the client and discuss alternative behaviors. Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. The client is in the crisis phase of the assault cycle. Therefore, the nurse must act immediately, using restraints and an intramuscular tranquilizer to prevent injury to others or further property damage. It is too late to ask the client to go to a quiet area to talk because the client's behavior is past the triggering phase. Giving the client an oral tranquilizer and preparing for a show of determination are nursing interventions used in the escalation phase. Processing the incident with the client and discussing alternative behaviors are interventions used in the postcrisis phase. A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting? Intellectualization Denial Regression Displacement Denial Denial is a protective and adaptive reaction to increased anxiety. It involves consciously disowning intolerable thoughts and impulses. This response is commonly seen in victims of sexual abuse. In intellectualization, the client attempts to avoid expressing emotions associated with the stressful situation by using logic, analysis, and reasoning. A client who uses regression reverts to an earlier developmental level in response to stress. With displacement, the client transfers his feelings for one person toward another, less-threatening person. A nurse is interviewing a rape victim who was assaulted 6 month ago. Which questions should the nurse ask the client to know the extent of physical symptoms of PTSD? Select all that apply. "Are you having trouble sleeping?" "Have you felt irritable or experienced outbursts of anger?" "Do you have heart palpitations or sweating?" "Do you feel numb emotionally?" "Do you ever feel as you are reliving the event?" "Are you having trouble sleeping?" "Have you felt irritable or experienced outbursts of anger?" "Do you have heart palpitations or sweating?" "Do you ever feel as you are reliving the event?" Page | 56 To learn whether the client is having physical symptoms of PTSD, the nurse should ask the client if she is having trouble sleeping and whether she is emotionally stable or given to bursts of irritability. The nurse should also find out if the client experiences heart palpitations or sweating. Reliving the event is called flashback and is a physical response to the event. Asking the client if she is feeling numb emotionally assesses the presence of avoidance reactions, not physical manifestation of PTSD. The nurse should ask the client whether she has upsetting thoughts and nightmares to assess for the presence of intrusive thoughts. A physician who fails to obtain informed consent before performing a procedure is subject to liability for: medical battery. assault. false imprisonment. battery. medical battery Medical battery, intentional and unauthorized harmful or offensive contact, occurs when a client is treated without informed consent. Assault is the threat of unlawful force to inflict bodily injury upon another. False imprisonment is detention or imprisonment contrary to provision of the law. Battery is intentional and unpermitted contact with another. A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next? Contact the physician and apply physical restraints as instructed by the physician. Apply physical restraints to protect the client, then contact the physician for orders. Place the client in seclusion and contact the physician for further orders. Call security to restrain the client and put him in seclusion for the safety of the unit. Apply physical restraints to protect the client, then contact the physician for orders. A nurse may place a client in physical restraints if he poses a threat to himself or others and all less- restrictive interventions have failed. A nurse may place a client in restraints without a physician's order but must obtain an order within 1 hour of restraint application. Secluding the client, with or without security involvement, doesn't protect him from injury. A client's face is flushed. The client is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle? triggering escalation crisis aggressive escalation The escalation phase of the assault cycle involves agitation, swearing, screaming, demanding, and provocative behaviors with loss of reasoning ability. Page | 57 Some behaviors in the triggering phase involve muscle tension, irritability, restlessness, perspiration, and changes in breathing and voice quality. The crisis phase involves loss of self-control, hitting, scratching, kicking, and throwing things. "Aggressive" is not a phase of the assault cycle. A client with bipolar disorder, manic phase, is yelling at visitors. The client's face is flushed and his fists are clenched. Which nursing action should be taken first? Summon security to escort the client to his room. Administer IM lorazepam. Direct the client to his room for a time-out. Discuss the problem with the client. Direct the client to his room for a time-out. The client is in the escalation phase of the assault cycle. Applying the principle of the least restrictive alternative, such as a time-out, is the nurse's first action. Calling security to forcibly escorting the client to his room is more restrictive and not indicated at this time because the client has not lost control. Administering IM lorazepam is not indicated because the client has not lost control. The nurse might offer oral lorazepam if the client is having trouble calming down while in time-out. Discussing the problem is not appropriate in the escalation phase but is appropriate in the triggering phase. A psychiatric-mental health nurse is assessing a client who has been referred for care following a violent assault. Which finding would the nurse most likely document as reflecting the diagnostic criteria for posttraumatic stress disorder (PTSD)? Select all that apply. The client describes oneself as being constantly "on edge." The client states, "All I can think about these days is the attack." The client states that the client has a limited support network. The client states "completely avoiding the neighborhood where the attack occurred." The client admits that recent withdrawal from many of friends. The client describes oneself as being constantly "on edge." The client states, "All I can think about these days is the attack." The client states "completely avoiding the neighborhood where the attack occurred." Hyperarousal, avoidance of places associated with a trauma, and pervasive reminders of a trauma are criteria for PTSD. The nurse should address the client's social isolation and limited support network, but these are not diagnostic criteria for PTSD. Page | 60 A nurse is caring for pt who has suspected viral skin lesion. Which of the following laboratory findings should the nurse expect to review to confirm this diagnosis? Use cotton-tipped application to obtain fluid from the lesion, Place the specimen tube on ice after obtaining sample. A nurse in a clinic is preparing to obtain a skin specimen from a client who has suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply) Apply warm compresses to the affected area. A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? "I should apply an antibiotic ointment to the area" A nurse is providing discharge instructions to a pt who has a skin biopsy with sutures. The nurse should identify that which of the following client statements indicated that the teaching has been effective? "Apply the topical medication for up to 2 weeks after the fungal lesions are gone." A nurse is providing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include? Apply an occlusive dressing after application, Wear gloves after application to lesions on the hands, avoid applying in skin folds A nurse is providing information about a new prescription for corticosteroid cream to a pt who has mild psoriasis. Which of the following instructions should the nurse include? (Select all the apply) Administer a psoralen medication before the treatment A nurse is teaching a pt who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? Calcium A nurse is educating a pt on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following laboratory values should the nurse monitor? Place the child in a bath with colloidal oatmeal. A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? Anorexia A nurse is caring for a client who has contact dermatitis and has new prescription for diphenhydramine. For which of the following adverse effect should the nurse monitor? Superficial thickness Page | 61 A nurse in a provider's office is assessing a pt who has a sever sunburn. Which of the following classifications should the nurse use to document the burn? Inhalation injury A nurse is caring for a client who has sustained burns over 35% of total body surface area. The pt's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the pt has which of the following? Temperature 36.1C (97F), Hyperkalemia, Hyponatremia A nurse is assessing a pt who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hrs ago. Which of the following are common findings during this phase? Intravenous A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full- thickness burns over 60% of the body 24 hrs. ago. The nurse should plan to use which of the following routes to administer the medication? Limit visitor in the pt's room, Increase protein intake, Restrict fresh flowers in the room. A nurse is planning care for an adult client who sustained sever burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) Flumazenil A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer. Assess oxygen saturation A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to pt during the induction of anesthesia. Which of the following is the priority nursing action? Infuse iced IV fluids, Provide 100% oxygen, Place a cooling blanket on the pt, Administer IV dantrolene A nurse is caring for a pt who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all the apply) Provide airway support A nurse is caring for a pt who develops a systemic toxic reaction following regional block. Which of the following actions should the nurse take? Place the head of the bed flat A nurse is caring for a pt who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? Page | 62 Creatine 2.8 mg/dL, Blood glucose 235 mg/dL, WBC 17,850/mm3 A nurse is assessing a pt's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all the apply) Take your medication with a sip of water before surgery, Splint the abdominal incision with a pillow when coughing and deep breathing, Anti-embolism stockings are applied before surgery. A nurse is providing preoperative teaching to a pt who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply) Ensure the pt understands information about the procedure, witness the pt signing the informed consent form, determine if the pt is capable of understanding the reason for the procedure. A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following action should the nurse take? (Select all that apply) Inform the surgeon of the elevated temperature A nurse is caring for a pt who is schedules for an exploratory laparotomy. The pt's temperature is 39C (102.2F) orally. Which of the following actions should the nurse take? Remove the nail polish on fingers and toes A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? Place the client in a lateral position. A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following action should the nurse perform first? Encourage use of the incentive spirometer every 2hr., Instruct the pt to splint the incision when coughing and deep breathing, Reposition the pt every 2hr., Assist with early ambulation. A nurse is planning care for a pt to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) Assess bowel sounds A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? "It allows preset pressure delivered during spontaneous ventilation." A nurse is caring for a patient receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statement by the nurse indicated an understanding of PSV? Pale Skin, Elevated blood pressure Page | 65 A nurse is caring for a group of patients. Which of the following patients are at risk for a pulmonary embolism? (Select all that apply) Pleural friction rub, Petechiae, Tachycardia A nurse is assessing a patient who has pulmonary embolism. Which of the following manifestation should the nurse expect? (Select all that apply) Administer oxygen therapy A nurse is reviewing prescriptions for a patient who has acute dyspnea and diaphoresis. The patient states, "I am anxious and unable to get enough air." Vital signs are HR 117/min, respirations 38/min, temperature 38.4 degree C (101.2 degree F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? Deviation of trachea, Pleuritic pain, Tachypnea A nurse is assessing a patient following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply) "Notify your provider if you experience a productive cough." A nurse is reviewing discharge instruction for a patient who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include? Cyanosis, Paradoxical chest movement, Dyspnea, cyanosis A nurse in the emergency department is assessing a patient who sustained multiple rub fractures and has flail chest. Which of the following findings should the nurse expect? (Select all that apply) A patient who experienced acute drug toxicity. A patient who has dysphagia. A patient following coronary artery bypass graft surgery. A nurse is reviewing the health records of five patients. Which of the following patients are at risk for developing acute respiratory syndrome? (Select all that apply) Respitory Acidosis A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.33 is 47 mmHg and HCO3 is 24 mEq/L. Interpret the ABG Metabolic Alkalosis. A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.47, PCO2 is 42 mmHg and HCO3 is 27 mEq/L. Interpret the ABG Respiratory Alkalosis. A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.48, PCO2 is 33, and HCO3 is24 mEq/L. Interpret the ABG. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? Page | 66 c. Heparin prevents the development of new clots in the coronary arteries. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased 1. Pressure in the portal vein Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful? Low-fat, high-carbohydrate meals Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? Albumin level Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? Passage of two or three soft stools daily A young woman who is 4 months pregnant comes into the ED with complaints of terrible indigestion pain, N/V and tooth pain. Which assessment finding collected by the admitting nurse suggests it is an AMI instead of gallbladder attack? Pain lasted longer than 30 min with no decrease in intensity or rest The nurse is caring for a patient with cirrhosis of the liver who has developed esophageal varices. Best explanation for development of varices is: Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to esophageal vessels, increasing pressure and causing varicosities The nurse will teach the patient diagnosed with Hep B about: measures for improving the appetite A 24 year old female contracts hepatitis from contaminated food. During the acute phase of the patient's illness, the nurse would expect to reveal anti-hepatitis A virus immunoglobulin A 51 year old woman had incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to: turn, cough and deep breath every 2 hours Which clinical manifestation would the nurse expect a client diagnoses with acute cholecystitis to exhibit? Nausea, vomiting and anorexia Page | 67 A 55 year old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing negative for hepatitis. Which question by the nurse is most appropriate? Do you use any over the counter drugs? A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is priority to be reported? Hand spasms present when blood pressure is checked A serum potassium level of 3.2 is reported for a patient with cirrhosis who has scheduled doses of spironolactone and Lasix, what should the nurse do? Administer the spironolactone When developing a teaching plan for a 61 year old man with the following risk factors for CAD to decrease the risk for acute coronary syndrome, the nurse's early focus should be the: elevation of the patient's low density lipoprotein (LDL) level A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? Maintaining cardiac monitoring A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? "Sexual activity uses about as much energy as climbing two flights of stairs." Spironolactone is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following side effects Hyperkalemia T/F: A positive finding in a patient with hepatic encephalopathy is spider angiomas FALSE Patient is in end stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? Evaluating the client's ammonia level Assessing the client's neurological status every 2 hours For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? Applying pressure to injection sites Page | 70 A client is brought to the emergency room in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's orders? Infuse 1 liter of normal saline per hour. Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm with BP 180/90, P 120, RR 20? Propranolol (Inderal) A patient asks a nurse why the provider bases his medication regimen on his HbA1c instead of his log of morning fasting blood glucose results. Which of the following is an appropriate response by the nurse? "HbA1c indicates how well your blood glucose has been regulated over the last 3 months." A nurse is reviewing the laboratory findings of a patient who has suspected hyperthyroidism. An elevation of which of the following supports this diagnosis? Triiodothyronine (T3) After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to . balance fluids and electrolytes. The patient with diabetes mellitus is going home following angioplasty. The nurse observes that the patient walks to the restroom barefoot, although slippers are in reach. The priority nursing diagnosis for this patient is which of the following? Risk for infection related to impaired tissue perfusion and walking barefoot. Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? New-onset changes in the patient's vo A patient is being treated for Addison's disease with glucocorticoid replacement medication. The nurse evaluates the patient's understanding of medication therapy when the patient makes which for the following statements? I should call my doctor if I gain 2 pounds, feel weak, or have a cold. Page | 71 A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance? Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery Which of the following things must the nurse working with diabetic clients keep in mind about Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS It has a higher mortality rate than Diabetic Ketoacidosis A nurse in a provider's office is reviewing the health record of a patient who is being evaluated for Grave's disease. Which of the following is an expected lab finding for this patient? Decreased thyroid stimulating hormone A patient with adrenocortical insufficiency verbalizes concern that she will lose muscle mass, gain weight, get a buffalo hump, and moon face if she takes the prescribed glucocorticoid. The nurse's best response is based on the fact that: these adverse effects can be minimized with proper diet and exercise. Which assessment finding for a 33-year-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? Temperature 103.8° F (40.4° C) A nurse is providing teaching to a patient who has a new diagnosis of diabetes insipidus. Which of the following statements by the patient requires further teaching "I can drink up to 2 quarts of fluid a day." A patient with hypoparathyroidism is to be discharged home after stabilization of fluid and electrolyte levels. Which of the following critical concepts does the nurse teach the patient prior to discharge? Strategies to prevent falling and how to plan meals high in calcium. Which of the following combinations of adverse effects must be carefully monitored when administering IV insulin to a patient with DKA? Hypokalemia and hypoglycemia The patient who has a long history of type I diabetes mellitus is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the patient's clothes, and dry skin. Which of the following actions should the nurse take next? Assess blood glucose level for hyperglycemia and check urine for ketones. Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? Increasing serum sodium levels Page | 72 A 70-year-old patient admitted a few hours ago with a blood glucose level of 750 mg/dL is being treated for hyperosmolar hyperglycemic nonketotic coma (HHNK) with intravenous regular insulin at 10 units/hour, normal saline with 40 mEq of potassium per liter infusing at 250 mL/hr, and oxygen at 2 L/min. The patient is oriented when stimulated, and fasting blood sugar has dropped to 400 mg/dL. The patient starts demanding to get out of bed and the nurse notes the skin feels cool and moist. The nurse should do which of the following? interpret this as a sign of hypoglycemia and check his blood sugar A nurse is beginning her shift. In assessing a patient who has Cushing's disease, which of the following is the priority assessment? . Daily weights Which condition, if not treated appropriately, can lead to water intoxication? SIADH A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n): decreased serum sodium. A female patient newly diagnosed with hypothyroidism indicates that she no longer wants to participate in evening social activities stating, "There is too much walking, and I prefer to go to bed early. I see enough of my friends at work every day." The nurse formulates which of the following as a priority nursing diagnosis for this patient? Fatigue related to reduced metabolic rate as evidenced by desire to avoid evening activities after work A patient receiving desmopressin (DDAVP) for treatment of Diabetes Insipidus, is noted to be drowsy, listless, and complains of recent onset of headaches. The nurse is concerned about possible water intoxication A patient with a history of cardiac disease has been recently diagnosed with hypothyroidism, and levothyroxine (Levoxyl) has been prescribed. Which of the following signs and symptoms related to this medication are most important for the patient to report to the physician? Chest pain A nurse is caring for a patient who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? Decreased specific gravity Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves' disease? Antithyroid medications may take several months for full effect Page | 75 C. Hyper-oxygenate the pt D. Assess the skin of the upper chest A. Check oxygen saturation Which ABG result is most important for the nurse to report immediately to the health care provider? A. pH 7.34, PaO2 80 mmhg, PaCO2 41 mmhg, O2 sat 98% B. pH 7.35, PaO2 85 mmhg, PaCO2 45 mmhg, O2 sat 95% C. pH 7.46, PaO2 90 mmhg, PaCO2 32 mmhg, O2 sat 98% D. pH 7.31, PaO2 91 mmhg, PaCO2 50 mmhg, O2 sat 96% D. pH 7.31, PaO2 91 mmhg, PaCO2 50 mmhg, O2 sat 96% You are assessing the respiratory system of an 80 year old pt, which finding indicates that you should take immediate action? A. Weak cough effort and non productive B. Anterior posterior view barrel-shaped chest C. Mucous membranes dry and intact D. Crackles bilaterally at lungs bases D. Crackles bilaterally at lungs bases Your pt is scheduled for a CT of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider? A. Patient is claustrophobic B. Patient is allergic to shellfish C. Patient recently used a bronchodilator inhaler D. Patient is not able to remove a wedding band E. BUN and creatinine levels are elevated B. Patient is allergic to shellfish E. BUN and creatinine levels are elevated Rationale: because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (like shellfish) and monitoring renal function before the CT scan are necessary. The other actions are contraindications for CT of the chest, although they may be for other diagnostic tests, such as MRI or pulmonary function testing. A clinic nurse prepared to teach a pt how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? A. Hand washing is the primary way to prevent spreading the condition to others B. Use of oral antihistamines for 2 wks before the allergy season may prevent reactions C. Corticosteroids nasal sprays will reduce inflammation, but systemic effects limit their use D. Identification and avoidance of environmental triggers are best way to avoid symptoms Page | 76 D. Identification and avoidance of environmental triggers are best way to avoid symptoms The nurse discusses management of upper respiratory infections (URI) with a pt who has acute sinusitis. Which statement by the pt indicates that additional teaching is needed? A. I can take acetaminophen (Tylenol) to treat my discomfort B. I will drink lots of juices and other fluids to stay well hydrated C. I can use my nasal decongestant spray until the congestion is all gone D. I will watch for changes in nasal secretions or the sputum that I cough up C. I can use my nasal decongestant spray until the congestion is all gone Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective A patient who had a total laryngectomy has a nursing diagnosis of hopelessness r/t loss of control of personal care. Which info obtained by the RN is the BEST indicator that the identified problem is resolving? A. The patient lets the spouse provide tracheostomy care. B. The patient allows the RN to suction the trach. C. The patient asks how to clean the trach stoma and tube. D. The patient uses a communication board to request "No visitors." C. The patient asks how to clean the trach stoma and tube. Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness. You are caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the MOST immediate action by the RN? A. The O2 sat is 88% B. Nose is red and swollen. C. Temp is 100.7F (37.8C) D. Patient ℅ level 9 (0 to 10) pain A. The O2 sat is 88% In a Med Surg unit, a patient is admitted with acute SOB. During initial assessment which action should the RN take? Page | 77 A. Tell the patient to lie down to complete a full PX assessment. B. Quickly ask specific questions about this episode of respiratory distress. C. Complete the admission database to check for allergies before treatment. D. Suspend the PX assessment and focus on the completion pulmonary function tests. B. Quickly ask specific questions about this episode of respiratory distress. A diabetic patient's ABG results are pH 7.29; PaCO2 33 mg Hg; PaO2 87 mm Hg; HCO3 19 mEq/L. The RN would expect which finding? A. Intercostal retractions B. Kussmaul respirations C. Low O2 sat (SpO2) D. Decreased venous O2 pressure B. Kussmaul respirations On auscultation of a patient's lungs, the RN hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the RN document this finding? A. Inspiratory crackles at the bases B. Expiratory wheezes in both lungs C. Abnormal lung sounds in the apices of both lungs D. Pleural friction rub in the right and left lower lobes A. Inspiratory crackles at the bases Your patient had a bronchoscopy. After the procedure, which intervention is most appropriate? A. Elevate the head of the bed to 80-90 degrees. B. Keep the patient NPO until the gag reflex returns. C. Place on bed rest for at least 4 hours after bronchoscopy. D. Notify the health care provider about blood-tinged mucus. B. Keep the patient NPO until the gag reflex returns. RN observes a student who is listening to a patient's lungs who is having no problem with breathing. Which action by the student indicates a need to review respiratory assessment skills? A. The student starts at the apices of the lungs and moves to the bases. B. The student compares breath sounds from side to side avoiding bon areas. C. The student places the stethoscope over the posterior chest and listens only during inspiration. D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth. C. The student places the stethoscope over the posterior chest and listens only during inspiration. RN admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching re: med use? Page | 80 8. A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. "Foods high in vitamin A and vitamin C are important." b. "I'll have to cut down on the amount of bacon I eat." c. "I'm so glad I don't have to give up my juicy steaks." d. "Vegetables, fruit, and high-fiber grains are important." ANS: C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct. 9. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report. ANS: D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis. 10. A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? a. "Maybe; preservatives, dyes, and preparation methods may be risk factors." b. "No; research studies have never shown those things to cause cancer." c. "There are other things you can do that will more effectively lower your risk." d. "Yes; preservatives and dyes are well known to be carcinogens." ANS: A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client's question. 1. The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology Page | 81 ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth. 2. The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy ANS: A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function. 3. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods. 4. A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? Page | 82 a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time Palpating both carotid arteries at the same time The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL Triglycerides: 198 mg/dL The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread Baked chicken breast, broccoli, tomatoes The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables. The nurse is working with a client who takes atorvastatin ( Lipitor ). The client's recent laboratory results include a blood urea nitrogen ( BUN ) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis. Page | 85 As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the client's disease is worsening. The other questions are useful, but not as important. An older client with PVD is explaining the daily foot care regimen to the family practices clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination." " My hands shake when I try to do things requiring coordination " Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion. A client is taking warfarin ( Coummadin ) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you." " No, it may interfere with the warfarin " Many foods and drugs interfere with warfarin, St. John's wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol." " No, women should only have one beer a day as a general rule " Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A "drink" is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman's size does not matter. Page | 86 A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound Client who had a first does of captopril ( Capoten ) and needs to use the bathroom Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom. A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure Distal pulse on affected extremity 2+/4+ Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as a 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately. Assess distal pulses and skin color A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours Page | 87 c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count Appropriate hand hygiene before giving care Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection. A client is receiving an infusion of alteplase ( Activase ) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate. Notify the Rapid Response Team Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the client's manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants Palpates the abdomen in four quadrants Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate. A nurse is caring for a client with deep vein thrombosis ( DVT ). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors Oxygen saturation of 98% Page | 90 " I can use a heating pad on my legs if it's set on low " Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline Ensure the client has a patent airway Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures. The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium. Assess the client's ankle-brachial index This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition. What nonpharmacologic comfort measures should the nurse include in the plan for a client with severe varicose veins? a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options Applying elastic compression stockings Elevating the legs when sitting or lying Reminding the client to do leg exercises ANS: B, C, D Page | 91 The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure A nurse is preparing a client for a femoropopliteal bypass operation. What action does the nurse delegate to the UAP? a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs Raising the side rails on the bed Recording baseline vital sings The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report. A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the UAP for deep vein thrombosis ( DVT ) prevention? a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises. Apply compression stockings Assist with ambulation Offer fluids frequently The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function A nurse is caring for a client on IV infusion of heparin. What action does this nurse include in the client's plan of care? a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. Page | 92 c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale. Assess the client for bleeding Monitor the daily activated partial thromboplastin time ( aPTT ) results Use an IV pump for the infusion Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related. A client is being discharged on warfarin ( Coumadin ) therapy. What discharge instructions is the nurse required to provide? A. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication Dietary restrictions Follow up laboratory monitoring Possible drug-drug interactions Reason to take medication The Joint Commission's Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted. Which statements by the client indicate good understanding of foot care in the peripheral vascular disease? a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best." " I will keep my feet dry, especially between the toes " " Lotion is important to keep my feet smooth and soft " " Washing my feet in room temperature water is best " Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails Page | 95 bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan. ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness." ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus. ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? Page | 96 a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler's position. ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain. ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help. ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?" Page | 97 ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider. ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor. ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed. The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene. ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the client's sheets.