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A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge? Continuous passive motion device Elevated toilet seat Trapeze bar
Compression garment ✔ Correct Answer-Elevated toilet seat
A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge. A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (select all that apply) Elevated WBC count Elevated amylase level Rebound tenderness Ascites
Anorexia ✔ Correct Answer-Elevated WBC count
A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix. Rebound tenderness A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client's abdomen. Anorexia A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? "I am aware that my diabetes is caused by an autoimmune disorder." "I know that my diabetes developed slowly over several years." "If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin." ✔ Correct Answer-"I am aware that
my diabetes is caused by an autoimmune disorder." Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This autoimmune reaction is often triggered by a viral infection.
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? WBC count 8,000/mm RBC count 6 million/mm BUN 24 mg/dL
Potassium 3.5 mEq/L ✔ Correct Answer-BUN 24 mg/dL
A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the client for increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate transplant rejection. A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take? Give detailed directions when addressing the client. Provide finger food at mealtime. Use written signs to redirect the client.
Seat the client at a large table for meals. ✔ Correct Answer-Provide finger food
at mealtime. The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal. A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube? Feel for exhaled air emerging from the endotracheal tube. Assess for bilateral breath sounds. Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels. ✔ Correct Answer-Check for end-tidal
carbon dioxide levels. According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement. A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (select all that apply) "I will avoid crowds." "I will wash my toothbrush weekly." "I will change my cat's litter box twice weekly." "I will take my temperature daily."
"I will eat plenty of fresh fruits and vegetables." ✔ Correct Answer-"I will avoid
crowds." The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce the risk of infection. "I will take my temperature daily."
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication? Coronary artery disease Retinopathy Cerebrovascular accident
Hypertension ✔ Correct Answer-Retinopathy
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness. A nurse in an emergency department is caring for a client who is confused, has a temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first? Measure the client's urine specific gravity. Administer oxygen using a high-concentration mask. Initiate gastric lavage with ice water.
Immerse the client in cold water. ✔ Correct Answer-Administer oxygen using a
high-concentration mask. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to ensure that the client has a patent airway and administer oxygen using a high-concentration mask to promote oxygen perfusion to vital organs. A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect? Decreased calcium levels Decreased somatotropin levels Increased glucose levels
Increased T4 levels ✔ Correct Answer-Increased T4 levels
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism. A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching? Walk 30 min daily at a comfortable pace. Limit saturated fat intake to 10% of total daily calories. Maintain a BMI of 30.
Consume at least 2,000 mg of sodium per day. ✔ Correct Answer-Walk 30 min
daily at a comfortable pace. A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit? BUN 16 mg/dL
Urine output 40 mL every hour for 3 hr Hct 42%
Surgical drain output 300 mL during an 8-hr shift ✔ Correct Answer-Surgical
drain output 300 mL during an 8-hr shift A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit. A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance? Breakdown of fatty acids Retention of carbon dioxide Hyperventilation in response to hypoxia
Ingestion of large amounts of bicarbonate ✔ Correct Answer-Retention of
carbon dioxide Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon dioxide can result from respiratory depression, inadequate chest expansion, airway obstruction, or decreased alveolar capillary diffusion. A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which. Of the following findings should the nurse identify as a manifestation of hypovolemia? Distended neck veins Rapid pulse rate Urine output 45 mL/hr
Decreased respiratory rate ✔ Correct Answer-Rapid pulse rate
A client who has hypovolemia has a rapid, weak pulse rate to compensate for the decrease in blood volume in an attempt to increase blood pressure. A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching? "Take a dose of loperamide each morning." "Increase your fluid intake to 1,000 milliliters per day." "Take psyllium in the evening."
"Consume a diet that is low in protein." ✔ Correct Answer-"Take psyllium in the
evening." A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements. A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority? WBC count Intake and output ABGs
Blood glucose level ✔ Correct Answer-ABGs
When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority assessment is to monitor the client's ABGs, including respiratory status.
A home health nurse is assisting a family member with planning care for a client who has Alzheimer's disease. Which of the following instructions should the nurse include? Remove clutter from rooms and hallways. Place a monthly calendar in the client's room. Use confrontation to manage the client's behavior.
Review the daily schedule with the client every morning. ✔ Correct Answer-
Remove clutter from rooms and hallways. The nurse should instruct the family member to remove clutter from rooms and hallways so the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client. A nurse is caring for a client who has dumping. Syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome? Weight gain Iron-deficiency anemia Hypercalcemia
Reduced heart rate ✔ Correct Answer-Iron-deficiency anemia
The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron- deficiency anemia. A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? "I will have to move out of my family's home until I am no longer contagious." "I will place my used tissues in a plastic bag." "I will cover my mouth with my hands when I have to cough."
"I will not go in public areas until I am cured." ✔ Correct Answer-"I will place my
used tissues in a plastic bag." The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client's sputum should be placed in a plastic bag and sealed to avoid spreading the infection. A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which
of the following adverse effects? ✔ Correct Answer-Thinning of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
Topical Glucocorticoids Side effects ✔ Correct Answer-Tiamcinolone
- Hypopigmentation
- Excessive hair growth (hypertrichosis)
- Thinning of the skin
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart
failure? ✔ Correct Answer-Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.
Left Sided Heart Failure ✔ Correct Answer-- Frothy sputum
- Dyspnea
- Wheezing Treatment: Fluid restriction & diuretics to decrease preload & pulmonary congestion
Right heart sided failure ✔ Correct Answer-- Dependent edma
- Jugular distention
- Weight gain A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that
the client is experiencing? ✔ Correct Answer-Respiratory alkalosis
- The pH is alkaline
- PCO2 is low representing alveolar hyperventilation & respiratory alkalosis A nurse is assessing a client who has Cushing's syndrome. Which of the following
findings should the nurse expect? ✔ Correct Answer-Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion. A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?
✔ Correct Answer-A pearly, waxy nodule.
- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy apperance from ocerexposure to the sun.
Melanoma ✔ Correct Answer-Irregular border and varigated colored lesions of
red, white, blue.
- Most often on the upper back or lower legs
Squamous cell carcinoma ✔ Correct Answer-Firm, nodular, and crusty lesion
with an ulcerated center from sun exposure, chronic irritation, burns, or irradiation to the skin.
weeping vescile ✔ Correct Answer-Herpes Zoster
- Weeping, blister type lesions. A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following
laboratory findings should the nurse expect? ✔ Correct Answer-LOW URINE
SPECFIC GRAVITY.
- Epinephrine
- Corticosteroids
- Oxygen A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which of the following adverse effects should the nurse instruct
the client to report IMMEDIATELY to the provider? ✔ Correct Answer-SKIN RASH.
- the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens- Johnson syndrome. The client should report this finding to the provider immediately.
Phenytoin side effects ✔ Correct Answer-- Skin Rash
- Bleeding gums
- Increased facial hair
- Constipation A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a COMPLICATION of the surgery?
✔ Correct Answer-CLEAR DRAINAGE OF DRESSINGS
- This is an indication of a cerebral spinal leak
lumbar laminectomy postoperative ✔ Correct Answer-- Slight elevation in
temperature
- No more than 125 mL of drainage in 4 hours
- Decreased bowel sounds due to anesthesia
- Monitor for paralytic ileus A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings should the nurse identify as a manifestation of RIGHT- SIDED
HEART FAILURE? ✔ Correct Answer-INCREASED ABDOMINAL GIRTH
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates ACCEPTANCE of the role change?
✔ Correct Answer-" I changed the floor plan of our homes to accommodate my
father's wheelchair. " A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to the nurse that the client is experiencing an
ADVERSE EFFECT of the medication? ✔ Correct Answer-THE CLIENT IS
BECOMING FLUSHED.
- Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome.
Red man sydrome ✔ Correct Answer-Results from infusing vancomycin too
rapidly. The nurse should infuse the medication over at least 60 min.
- Tachycardia
- Ototoxcity
- Renal failure
- Flushing A nurse is caring for a male client who has a new prescription for CYCLOSPORINE following a kidney transplant. Which of the following findings should the nurse
identify as an adverse effect of this therapy? ✔ Correct Answer-BUN 24 mg/dL.
- A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity
WBC normal range ✔ Correct Answer-5,000-10,
RBC count normal range ✔ Correct Answer-4.7-6.1 million
Potassium normal range ✔ Correct Answer-3.5-5.
A nurse is caring for a client who has DUMPING SYNDROME following a gastric resection. The nurse should monitor the client for which of the following
complications of DUMPING SYNDROME? ✔ Correct Answer-IRON DEFICIENCY
ANEMIA.
- The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia. A nurse is assessing a client who takes SALMETEROL to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication
has been effective? ✔ Correct Answer-THE CLIENT'S FORCED EXPIRATORY
VOLUME IS DECRESED AFTER TREATMENT WITH MEDICATION.
- Forced expiratory volume measures the amount of air the client exhales during 1 second and is part of pulmonary function testing. Effective use of a bronchodilator should increase the client's forced expiratory volume
Dumping syndrome ✔ Correct Answer-- Anorexia
- Iron deficiency anemia
- Hypocalcemia
- Tachycardia
- Rapid gastric emptying
- Nausea & abdomnial cramping A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following
statements by the client indicates an understanding of the teaching? ✔ Correct
Answer-" I WILL CHECK MY BLOOD SUGAR LEVEL BEFORE EXCERCISING. "
- Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise
include in the teaching? ✔ Correct Answer-A PCA PUMP WILL BE USED FOR
POSTOPERATIVE PAIN CONTROL.
- A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication. A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with NO CLEAR P WAVES. Which of the following cardiac dysrhythmias
should the nurse document? ✔ Correct Answer-ATRIAL FIBRILLATION.
- With atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm.
First-degree heart block ✔ Correct Answer-- Atrial impulses reach the ventricles
through the AV node at a slower-than-normal rate.
- P waves have a regular shape and appear consistently in front of the QRS complex.
Complete heart block ✔ Correct Answer-- Regular rhythm
- Low HR
- Clear P waves that outnumber QRS complexes
Ventricular tachycardia ✔ Correct Answer-- Rapid, regular rhythm
- HR: 140 +
- P waves not visible A nurse is caring for a client who is receiving peritoneal dialysis. Which of the
following actions should the nurse take? ✔ Correct Answer-REPORT CLOUDY
DIALYSATE DRAINAGE TO THE PROVIDER.
- The most serious complication of peritoneal dialysis is peritonitis, an inflammation of the peritoneum. Assessment findings include cloudy dialysate drainage, rebound abdominal tenderness, and diffuse abdominal pain. The nurse should report these findings immediately to the provider, who can then prescribe a fluid culture, quick exchanges to wash out mediators of infection, and antibiotics.
Dialysate interventions ✔ Correct Answer-- Do NOT use infusion pump
- Report cloudy dialysate drainage
- Warm solution using a heating pad or place in the warming section of cycling machine
- Dwell time: 4-8 hours
- Drainage: 10-20 minutes A nurse is assessing a client who has suspected APPENDICITIS. Which of the
following manifestations should the nurse expect? ✔ Correct Answer-- Elevated
WBC count (20,000+)
- Anorexia A nurse is planning preventative strategies for a client who is at risk for PRESSURE INJURIES. Which of the following actions should the nurse include in
the plan? ✔ Correct Answer-APPLY MOISTURIZER TO DAMP SKIN AFTER
BATHING.
- Applying a moisturizer to damp skin after bathing helps prevent dry skin. The drier the skin is, the greater the risk is for skin breakdown. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of
TYPE 1 DIABETES? ✔ Correct Answer-KETONES IN THE URINE
- Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels
Type 1 diabetes S/S ✔ Correct Answer-- Hyponatremia
- Increased serum osmolality
- Ketone in the urine
- Hyperglycemia A nurse is caring for a client who had a surgical repair of an ABDOMINAL AORTIC ANEURYSM 3 days ago. The client's vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following
actions is the nurse's priority? ✔ Correct Answer-ASSESS THE SURGICAL
INCISION FOR SIGNS OF INFECTION.
- A surgical wound infection typically appears 3 to 6 days following the surgery. Fever from the third postoperative day onward indicates that this client's greatest risk is either a wound infection or a pulmonary infection; therefore, this is the priority action the nurse should take. A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
✔ Correct Answer-"I may have mild cramping for several hours."
- The client should expect very little discomfort from the LEEP procedure, which is performed in ambulatory care using a painless electrical current. A nurse is assessing a group of clients. For which of the following clients should
the nurse make a referral to palliative care? ✔ Correct Answer-A CLIENT WHOSE
MEDICATIONS TO MANAGE PARKINSON'S DISEASE ARE NO LONGER EFFECTIVE.
- Palliative care is designed to maintain the client's current quality of life through symptom management, assist with decision making regarding care needs, and work with families to identify care outcomes A nurse is providing teaching to a client who has a new prescription for CEPHALEXIN oral suspension. Which of the following statements by the client
that the client has available at home prior to discharge? ✔ Correct Answer-
ELEVATED TOILET SEAT.
- A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge. A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a
microvascular complication? ✔ Correct Answer-RETINOPATHY.
- Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness.
diabetes macrovascular complications ✔ Correct Answer-- Coronary Artery
Disease
- Stroke
- Hypertension A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take?
✔ Correct Answer-MONITOR THE CLIENT FOR ANY ADVERSE REACTIONS.
- Although the client is a universal recipient and can receive any ABO blood type, the nurse should continue to monitor for any adverse reactions, which is standard procedure for any blood transfusion. A nurse is planning care for a client who had a lumbar LAMINECTOMY. Which of the following interventions should the nurse include in the plan of care?
✔ Correct Answer-TURN THE CLIENT BY LOG ROLLING WITH A TURNING SHEET.
- The nurse should turn the client by log rolling with a turning sheet to keep the client's back straight and to prevent back spasms from occurring. A nurse is teaching a client how to obtain a specimen at home for a FECAL OCCULT BLOOD TEST. Which of the following actions should the nurse instruct the
client to take for 3 days prior to collecting the specimen? ✔ Correct Answer-
AVOID EATING RED MEAT.
- A client should not eat red meat for 3 days before collecting the specimen because red meat contains hemoglobin, myoglobin, and some enzymes that can cause a false-positive result in a fecal occult blood test.
Fetal occult blood test ✔ Correct Answer-- Do not take NSAIDs for 7 days
- Do not eat raw vegetables, red meat, or citritus fruits for 3 days before
- Do not take Vitamin C supplements for 3 days before A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify
as the most reliable for verifying placement of the ET tube? ✔ Correct Answer-
CHECK FOR END-TIDAL CARBON DIOXIDE LEVELS.
- According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement. A nurse notes that a client's eyes are protruding slightly from their orbits. Which
of the following laboratory findings should the nurse expect? ✔ Correct Answer-
INCREASED T4 LEVELS.
- Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism. A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions
should the nurse include in the teaching? ✔ Correct Answer-INCREASE YOUR
INTAKE OF PROTEIN TO 1-1.5 G/KG PER DAY.
- A client who receives hemodialysis for chronic kidney disease needs protein to prevent a negative nitrogen balance and muscle wasting. A client who is receiving hemodialysis is allowed 1 g to 1.5 g of protein/kg/day A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse
take? ✔ Correct Answer-STOP THE HEPARIN INFUSION FOR 1 HOUR.
- According to the titration table, when the aPTT is greater than 95, the nurse should stop the infusion for 1 hr, then restart the infusion with a decrease of 3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80 kg (176.4 lb). A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's
priority? ✔ Correct Answer-ABGS.
- When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority assessment is to monitor the client's ABGs, including respiratory status. A nurse is assessing a client who has a new diagnosis of PERICARDITIS. Which of the following findings should the nurse identify as a manifestation of cardiac
tamponade? ✔ Correct Answer-PARADOXICAL PULSE.
- Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or more on expiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately. A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client
- The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal. A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the
nurse use while caring for the client? ✔ Correct Answer-SURGICAL MASK.
- The nurse should adhere to droplet precautions in addition to standard precautions for clients who have bacterial meningitis, provided the causative pathogen spreads via droplets.
- The nurse should place these clients in a private room and wear a mask when within 0.9 m (3 feet) of the client to prevent acquiring the infection.
- Clients should wear a mask whenever they are outside their room A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication
the client is at risk for fluid volume deficit? ✔ Correct Answer-SURGICAL DRAIN
OUTPUT 300 ML DURING AN 8 HOUR SHIFT.
- A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit. A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
✔ Correct Answer-CLOSE THE PINCH CLAMP ON THE CVC.
- The greatest risk to this client is air embolism resulting from accidental disconnection of the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the pinch clamp to prevent any further air from entering the system. When an air embolism occurs, air enters through the central vein into the right ventricle and lodges by the pulmonary valve, decreasing the amount of blood that is able to enter into the ventricle and the pulmonary arteries. A nurse is planning care for a client who is scheduled for surgery and has a LATEX ALLERGY. Which of the following actions should the nurse plan to take?
✔ Correct Answer-PLACE MONITORING CORDS & TUBES IN A STOCKINETTE.
-The nurse should place monitoring devices in a stockinette to prevent direct contact with the client's skin. A nurse is providing preoperative teaching about stool consistency to a client who will undergo a COLECTOMY with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the
teaching? ✔ Correct Answer-THE STOOL WILL HAVE A HIGH VOLUME OF LIQUID.
- The nurse should include in the teaching that when peristalsis returns, the client can have an initial period of high-volume liquid stool output, more than
1,000 mL/day. Later, as the proximal small bowel adapts, stool volume should decrease. A nurse is providing teaching to a client who has a new prescription for LEVOTHYROXINE to treat hypothyroidism. Which of the following statements by
the client indicates an understanding of the teaching? ✔ Correct Answer-IF MY
HEART STARTS RACING, MY PROVIDER MIGHT NEED TO ADJUST MY DOSAGE.
- Levothyroxine increases metabolism, which can increase oxygen consumption and heart rate. If the client's heart is racing, the dosage might be too high, causing thyrotoxicosis with manifestations of tachycardia, insomnia, tremors and nervousness, hyperthermia, heat intolerance, and sweating. The provider should retest the client's thyroid hormone levels and adjust the dosage accordingly. A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be
experiencing abdominal pain? ✔ Correct Answer-LEFT LOWER QUADRANT.
- Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to move stool into the rectum. Therefore, the pain with this disorder is often in the left lower quadrant. A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?
✔ Correct Answer-ORAL CONTRACEPTIVES WERE TAKEN FOR THE LAST 6 YEARS.
- Clients who take hormones, such as estrogen therapy, fertility drugs, and oral contraceptives, have an increased risk of developing breast cancer. A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the
nurse include in the teaching? ✔ Correct Answer-TAKE PSYLLIUM IN THE
EVENING.
- A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for
ventilator-associated pneumonia (VAP)? ✔ Correct Answer-Monitor for oral
secretion every 2 hours Provide oral care every 2 hours Assess the client daily for readiness of extubation. A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information
should the nurse include in the client's plan of care? ✔ Correct Answer-ASSESS
THE PICC INFUSION SYSTEM SYSTEMATICALLY.
The nurse should assess the infusion system in a systematic fashion beginning with the insertion site, observing for signs of infection, and working upward and following the tubing to ensure that all connections are secure.
