Medical Surgical Proctored Exam 2024 Version New Latest Exam Best Studying Material, Exams of Medicine

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Medical Surgical Proctored Exam 2024 Version New

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A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction? ---------- Correct Answer ------- --- *The ST segment is above the isoelectric line. Rationale: Myocardial infarction is classified as ST elevation (MI STEMI) or non-ST elevation (MI NSTEMI). ST elevation is a manifestation of MI STEMI. A nurse is assisting with the care of a client who was admitted to the emergency department with reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how many hours after the onset of chest pain? ---------- Correct Answer ---------- *24 hr Rationale: The nurse can anticipate that CK-MB will peak 18 to 24 hr after the onset of chest pain when acute myocardial infarction occurs. A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? ---------- Correct Answer ----------- Irrigate the catheter as prescribed. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? -- -------- Correct Answer ----------- "I will take a stool softener until my eye is healed." A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? ---------- Correct Answer ----------- Hypertension A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match? ---------- Correct Answer ---------- *Lactated Ringer's Rationale: Lactated Ringer's solution is administered to the client who has hypovolemic shock because it contains electrolytes and expands plasma volume.

A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? ---------- Correct Answer ---------- *Determine the patency of the tubing. Rationale: The first action the nurse should take when using the nursing process is to determine the patency of the tubing by assessing for kinks in the tubing or the presence of clots. A lack of drainage may be the result of kinked drainage tubing, a blood clot, or tissue blocking the drainage tubing. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? ---------- Correct Answer ---------- * "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." Rationale: This response is therapeutic because it gives the client the information that she needs to cope, and reassures the client of the plan to address her comfort, and allows for further communication of concerns by the client. A nurse is assisting with planning care for a client who is recovering from a left- hemispheric stroke. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---------- *Re-establish communication. Rationale: A stroke is an interruption of the blood supply to a part of the brain, resulting in oxygen-deprived brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-hemispheric stroke, the nurse can anticipate that the client will have some degree of aphasia and will require communication-focused nursing interventions and speech therapy to re-establish communication. A nurse is assisting with the care of a client who is in hemorrhagic shock and has a prescription for packed red blood cells. Which type of blood can be administered to the client while awaiting blood from a type and cross-match? ---------- Correct Answer -------- -- *Type O Rationale: Type O blood can be given to clients who have any of the four blood types. A nurse in the emergency department is collecting data from a client who was admitted following a bee sting. Which of the following findings should the nurse expect in a client who is experiencing anaphylaxis? ---------- Correct Answer ---------- *Hypotension Rationale: Hypotension is an expected finding for a client who is experiencing anaphylaxis due to vasodilation. A nurse is caring for a client who was admitted to the emergency department immediately following a snake bite to her forearm. The client suspects that the snake

was venomous. Which of the following nursing interventions is appropriate? ---------- Correct Answer ---------- *Determine the need for a tetanus immunization. Rationale: Clients who have a puncture wound to the skin due to a snakebite are at risk for tetanus because the fangs of the snake can be contaminated with bacteria from soil or feces. Therefore, the nurse should ask the client when she had her last tetanus immunization. A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- *Apply pressure directly to the wound. Rationale: The greatest risk to this client is injury from hemorrhaging; therefore, the priority intervention is to control bleeding and apply direct pressure to the area or to the artery proximal to the wound. A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Begin the Heimlich maneuver. Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. A nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. Which of the following actions should the nurse take to determine the client's level of alertness? ---------- Correct Answer ---------- *Check the client's eye opening in response to verbal stimuli. Rationale: Checking the client's eye opening response to verbal stimuli is an appropriate method to check alertness. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the following findings should the nurse expect? ---------- Correct Answer ----- ----- *Oliguria Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys. A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention by the nurse? ------ ---- Correct Answer ---------- *Check the client's respiratory rate.

Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's lung sounds. Checking the client's respiratory rate can determine if the client is in respiratory distress. A nurse is caring for a client following the application of an aquathermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn? ---------- Correct Answer ---------- *Erythema Rationale: Erythema is a manifestation of a superficial burn. A nurse is caring for a client who is at risk for shock. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Increased blood pressure Rationale: Decreased blood pressure is a manifestation of shock. A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Acetone odor to breath Rationale: Acetone odor to breath is an expected finding for ketoacidosis. A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- *Test the drainage for glucose. Rationale: The greatest risk to a client who has a basal skull fracture is injury from cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage for glucose. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia? ---------- Correct Answer ---------- *Prevent bladder distention. Rationale: Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? ---------- Correct Answer ---------- *Abnormal vaginal bleeding

Rationale: The nurse should expect the client to experience abnormal vaginal bleeding, including postmenopausal bleeding and bleeding between normal periods. Abnormal vaginal bleeding is the most common finding in endometrial cancer in premenopausal women. A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider? ---------- Correct Answer --- ------- *Abdomen is distended Rationale: When using the airway, breathing, circulation approach to client care, the nurse should recognize the presence of abdominal distention has the potential to compromise the client's respiratory status as the distention increases abdominal pressure on the diaphragm and impairs ventilation. This is the priority finding for the nurse to report A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority? ---------- Correct Answer ---------- *Altered level of consciousness Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is for the nurse to monitor the client's altered level of consciousness. A fracture of one of the long bones of the body places the client is at risk for fat embolism, which causes a decrease in oxygenation and alters the client's level of consciousness. A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan? ---------- Correct Answer ---------- *Change the nasal drip pad as needed. Rationale: The nurse should change the nasal drip pad as needed because the client will have nasal packing and bloody nasal drainage until the surgical site is healed. A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ---------- *Empty the ostomy pouch when it is 2/3 full. Rationale: The ileal conduit cannot store urine the way the bladder did; urine will flow continuously into a collecting device. Emptying the device when the pouch is 2/3 full will prevent leakage, skin irritation, and infection. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects? ---------- Correct Answer ---------- *To prevent blood clotting

Rationale: Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the nurse should instruct the client the aspirin is prescribed for clients who have coronary artery disease to prevent myocardial infarction caused by clots in the coronary arteries. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Loss of peripheral vision Rationale: The nurse should expect to find the client experiencing a gradual loss of peripheral vision with a narrowing of the visual field with open-angle glaucoma. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority? ---------- Correct Answer ---------- *Potassium 2.5 mEq/L Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is a potassium level of 2.5 mEq/dL. In the presence of fluid volume deficit, potassium depletion can occur. Complications from hypokalemia include cardiac and respiratory manifestations. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching? ---------- Correct Answer ---------- * "I will take a tub bath instead of a shower." Rationale: To reduce the risk of infection, the client should avoid tub baths following a total abdominal hysterectomy. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take? ---------- Correct Answer - --------- *Ensure the client's weights are hanging freely from the bed. Rationale: The nurse should ensure that the client's weights are hanging freely from the bed to maintain the client in proper body alignment and should never be removed without a provider prescription or the development of a life-threatening situation that requires removal. A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include? ---------- Correct Answer ---------- *Take this medication between meals. Rationale: Although taking iron supplements with food can decrease adverse effects, it also drastically reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron is most effective when supplements are taken in between meals.

A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend? ---------- Correct Answer ------- --- *Wash daily with an antibacterial soap. Rationale: The nurse should plan to have the client wash the area daily with an antibacterial soap to promote tissue health and treat the infection. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? ------ ---- Correct Answer ---------- *Take temperature once a day. Rationale: The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is present due to the client's altered immune system. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? ---------- Correct Answer ---------- *Provide humidified oxygen. Rationale: Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? ---------- Correct Answer ---------- *Obtain a pair of slipper socks for the client. Rationale: Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider? ---------- Correct Answer ---------- *Thick, red-colored urine Rationale: The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be reported to the provider immediately. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket? ---------- Correct Answer -------- -- *Shivering Rationale: The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can cause the client's temperature to increase.

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ---------- * "I should avoid injecting insulin into my thigh if I am going to go running." Rationale: The nurse should reinforce that the client should avoid injecting insulin into an area that will soon be exercised to avoid increasing the absorption rate of the insulin. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? ---------- Correct Answer ---------- *Cover the client's wound with a moist, sterile dressing. Rationale: According to evidence-based practice, the nurse's first action should be to cover the wound with a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the tissue moist. A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect? ------ ---- Correct Answer ---------- *Hyperventilation Rationale: The nurse should expect to find hyperventilation in a client who is experiencing metabolic acidosis. The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? ---------- Correct Answer ---------- *Avoid bending at the waist. Rationale: The nurse should reinforce that the client should avoid bending at the waist as this increases intraocular pressure; the client should be instructed to flex the knees and crouch instead. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- *Check the client's vital signs. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the

dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? ---------- Correct Answer ---------- *Purulent Rationale: Purulent describes drainage that is thick yellow, green, or brown in color. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching? ---------- Correct Answer ---------- *Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. Rationale: The nurse should administer analgesics prior to initiating any exercise program for the client who has had joint arthroplasty. It is important that analgesics are administered in time for the medication to work before the start of the exercise program to ensure discomfort is minimized. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ---------- *Avoid medications in capsule or enteric form. Rationale: The client should not take medications in capsule or enteric form because the medication may enter the pouch undigested. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make? ---------- Correct Answer ---------- * "Large incisions will be made in the burned tissue to improve circulation." Rationale: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has had a deep burn and is experiencing significant swelling. The swelling that occurs secondary to burn injuries that completely encircle a body part, such as an arm or the chest, can cause tightness and constriction of underlying tissue and can shut off circulation in the affected area. Making surgical incisions into the burned tissue allows the skin to expand and re-establish circulation. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report? ---------- Correct Answer ---------- *Decreased color perception Rationale: Visual manifestations associated with cataracts can include decreased color perception and decreased visual acuity, even in daylight. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube.

Which of the following interventions should the nurse include in the plan of care? ---------

• Correct Answer ---------- *Maintain the client in Fowler's position. Rationale: The nurse should place the client in Fowler's position to reduce pressure on the diaphragm and to promote function of the nasogastric tube. A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper gastric pain. Which of the following statements should the nurse include in the teaching? ---------- Correct Answer ---------- * "You will remain NPO for 8 hours before the procedure." Rationale: The nurse should include in the teaching for the client to remain NPO for 8 hr before the procedure to have the stomach free of food contents, decrease vomiting, and decrease the risk for aspiration. A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? ---------- Correct Answer ---------- *Postictal phase Rationale: The postictal phase is the recovery period following a tonic-clonic seizure. The client might be confused or agitated after a seizure and might sleep for several hours. A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Monitor intake and output hourly Rationale: The nurse should closely monitor the client for signs of fluid imbalance. This includes hourly monitoring of intake and output, along with daily weights. If there are sudden changes, or the urinary output is less than 30 mL/hr, the provider must be notified immediately. A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make? ---------- Correct Answer ---------- *The pain will dissipate if you ambulate frequently." Rationale: The client who has right shoulder pain following the procedure should ambulate as soon and as much as possible to dissipate the carbon dioxide gas that was injected into the abdominal cavity to visualize and access the abdominal structure. The carbon dioxide causes referred pain in the clavicle and shoulder area. A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions

should the nurse take? ---------- Correct Answer ---------- *Verify that the suction regulator is on. Rationale: The nurse should verify that the suction regulator is turned on because low continual bubbling will occur when the suction is on and there are no kinks in the tubing. A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication? ---------- Correct Answer ---------- *Iron Rationale: Epoetin alfa treats anemia by stimulating the production of red blood cells. Supplemental iron is needed for the production of hemoglobin and red blood cells by the bone marrow. The client should take supplemental iron when taking epoetin alfa. A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? ---------- Correct Answer ---------- *Ineffective airway clearance related to thick, copious secretions Rationale: According to the airway, breathing, circulation (ABC) priority-setting framework, the priority action is the client's need for adequate oxygenation. A client who has a new tracheostomy requires frequent suctioning in the early postoperative period because of copious secretions and the decreased effectiveness of the cough mechanism. A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long- term goals is appropriate with regard to the client's mobility? ---------- Correct Answer ---- ------ *Propel a wheelchair equipped with knobs on the wheels. Rationale: A client who has an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness. The addition of knobs on the wheels will help the client use the wheelchair more effectively. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non- melanoma skin cancer? ---------- Correct Answer ---------- *Sun exposure Rationale: According to evidenced-based practice, the nurse should identify exposure to the sun as the leading cause of non-melanoma skin cancer. Ultraviolet light radiation from the sun can cause cancerous changes in the skin. Decreased ozone protection has increased the amount of radiation exposure and increased the risk of cancer for clients regardless of skin color. Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help

confirm the client is experiencing manifestations of menopause? ---------- Correct Answer ---------- *Do you sleep well at night?" Rationale: Menopause causes vasomotor instability, which can cause night sweats and sleep disturbances. Therefore, this is an appropriate question for the nurse to ask. A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching? ---------- Correct Answer ---------- *Fresh berries Rationale: The nurse should include fresh berries (blackberries, strawberries, blueberries, and cranberries), coffee, kale, and dark chocolate as food sources high in antioxidants. A nurse is assisting with caring for a client who has a new concussion following a motor- vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? ---------- Correct Answer ---------- *Lethargy Rationale: An early manifestation of increased intracranial pressure is lethargy. The nurse should monitor and report any changes in the client's level of consciousness, such as restlessness or disorientation, because these are early manifestations of increased intracranial pressure. A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? ---------- Correct Answer ---------- * "This test will measure the intraocular pressure of the eye." Rationale: A tonometry examination provides a precise and simple way to measure intraocular pressure. This is a component of a comprehensive eye examination and is crucial for clients who have glaucoma or who are at high risk for developing intraocular hypertension. A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider? ---------- Correct Answer ---------- *Increase in serum creatinine Rationale: The nurse should identify the elevated serum creatinine level as the priority finding to report. Cyclosporine is nephrotoxic, so an increase in the creatinine and BUN levels can indicate the medication dosage is too high and must be decreased to recover renal function.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Drop in systolic BP more than 10 mm Hg on inspiration Rationale: The nurse should expect the client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or pericardial tamponade. A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Attempt to determine what the client was looking for. Rationale: Clients who have Alzheimer's disease frequently exhibit wandering behavior when they have an unmet need. The nurse should attempt to discover the reason for the client's wandering, which could include a need for toileting, uncontrolled pain, or searching for a familiar object. A nurse is caring for a client immediately followina a cardiac catheterization with a remoral artery approach. Which of the followina actions should tne nurse take? ---------- Correct Answer ---------- *Check pedal oulses every 15 min. Rationale: The Observation or a client who has undergone a cardiac cathetenzation includes monitoring the client's pulses below the puncture site. A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza? ---------- Correct Answer ---------- *The composition of the influenza vaccine changes yearly. Rationale: Influenza outbreaks occur annually and the prevalent influenza viruses change yearly. Consequently, the previous year's influenza immunization will not protect a client exposed to the current year's influenza strains. A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Help the client write down questions to ask his provider. Rationale: To empower the client in decision-making, the nurse should help the client write down questions to ask the provider. In doing this, the nurse acts as a client advocate to address the client's specific questions in a concrete, measurable way. A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following

responses should the nurse make? ---------- Correct Answer ---------- * "It must be hard to see your mother so ill and upset." Rationale: This response is therapeutic because it demonstrates empathy and acknowledges the son's feelings of helplessness and powerlessness. A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? ---------- Correct Answer ---------- *Forgetfulness gradually progressing to disorientation Rationale: Dementia usually appears first as forgetfulness. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary, daily activities to severe memory loss and complete disorientation with withdrawal from social interaction. A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---- ------ *Monitor client's cardinal fields of vision. Rationale: The nurse should assess for nystagmus, abnormal jerking movements of the eyes, by evaluating the six cardinal fields of gaze. Nystagmus is a manifestation of labyrinthitis. A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---------- *Monitor platelet levels Rationale: The nurse should monitor platelet levels along with other laboratory results related to blood coagulability and the medication therapy for the treatment of a deep vein thrombosis. Initially, medications such as heparin or enoxaparin are administered; laboratory test would include PTT. Later, warfarin therapy may be initiated for which PT/INR would be monitored. Platelets are monitored because the client is at risk for heparin inducted thrombocytopenia, placing the client at risk for bleeding. A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client? ---------- Correct Answer ---------- *Tuberculin skin test Rationale: The nurse should anticipate preparing the client to receive the tuberculin skin test (TST). The TST is an accurate screening tool for the presence of tuberculosis in an individual; however, it does not distinguish between previous exposure and active illness. The TBT requires multiple visits to the clinic, one to receive the injection and another visit, 48-72 hours later, to have the test read by a qualified health professional.

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? ------- --- Correct Answer ---------- *Urine output 650 mL/hr Rationale: Diabetes insipidus is an endocrine disorder of the anterior pituitary gland. A decrease in antidiuretic hormone results in an increasingly high output of very dilute urine. A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client? ------- --- Correct Answer ---------- * "I took my metformin before breakfast." Rationale: The nurse should identify clients taking metformin are at risk for lactic acidosis when receiving A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds? ---------- Correct Answer ---------- *Expiratory wheeze Rationale: Expiratory wheezing is associated with air movement through narrowed airways, as with the bronchospasm associated with asthma. A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? ---------- Correct Answer ---------- *Sitting, leaning forward over the bedside table. Rationale: Thoracentesis is aspiration of fluid or air from the pleural space. The nurse should place the client in a sitting position and leaning over a bedside table to ensure that the diaphragm is dependent. This facilitates the removal of accumulated fluid, which tends to pool in the bases of the pleural space. A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take? ---------- Correct Answer ---------- *Don clean gloves to remove the dressing. Rationale: Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Sterile gloves are not necessary until applying the new sterile dressing A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? ---------- Correct Answer ---------- *Denial Rationale: According to evidenced-based practice, the nurse should expect the client to first exhibit behaviors of denial following a cancer diagnosis or with other type of loss.

This initial stage of grieving is often a self-protective behavior used until the client tis ready to acknowledge and deal with the grief-causing issue. A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---------- *Place the client in a high Fowler's position. Rationale: The nurse should use measures to facilitate breathing in the client who has peritonitis. Placing the client into a high Fowler's position enhances lung expansion preventing respiratory complications and aids in localizing purulent abdominal materials. A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses? ---------- Correct Answer ---------- *Body weight Rationale: The nurse should weigh the client prior to and following dialysis in order to determine the amount of fluid losses/gains from dialysis. Each kilogram (2.2 lb) of weight gained or lost is equal to 1 L of fluid. A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? ---------- Correct Answer ---------- *Hypotension Rationale: Hypotension, tachycardia, tachypnea, low back pain, flushing, chills, and fever are manifestations of an acute hemolytic reaction to a blood transfusion. A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions? ---------- Correct Answer ---------- *A sensory warning that a seizure is imminent Rationale: n aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and may involve any of the senses. The client can report "hearing bells", "seeing lights", or "smelling something". A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? ---------- Correct Answer ---------- * I need something for the horrible pain in my eye." Rationale: Following cataract surgery, the client should expect only mild pain, and should immediately report any severe pain in the eye. Severe eye pain after surgery might indicate an increase in intraocular pressure, which can disrupt the surgical site

and cause permanent damage to the eye if the client does not receive treatment promptly. A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make? ---------- Correct Answer ---------- * "You may feel some cramping during the procedure." Rationale: The nurse should reinforce the use of breathing exercises to decrease the effects of cramping during the procedure. This response by the nurse is therapeutic because it appropriately addresses the client's concerns. A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? ---------- Correct Answer ---------- *Checking pupillary responses to light Rationale: Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light. Indications that intracranial pressure is increasing include lethargy, decreasing consciousness, tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a sluggish response to light and dilation of one or both pupils. A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects? ---------- Correct Answer ---------- *Reducing anxiety Rationale: Besides pain relief, postoperative opioid analgesics can help reduce anxiety and create feelings of well-being. A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report? ---------- Correct Answer ----- ----- *Frequent mood changes Rationale: Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Nervousness and frequent mood changes; hand tremors; a rapid, pounding, irregular heartbeat are common manifestations of hyperthyroidism A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? ---------- Correct Answer ---------- *Fever Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.

A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? --- ------- Correct Answer ---------- *Auscultate the client's abdomen. Rationale: The first action the nurse should take using the nursing process is to collect data by listening to the client's abdomen to determine the presence of bowel sounds before offering a choice of clear liquids. A common postoperative complication is paralytic ileus or delayed gastric emptying due to decreased peristalsis. Administering liquids to a client who does not have bowel sounds can cause the client to vomit. A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? -- -------- Correct Answer ---------- *The wound has a halo of erythema on the surrounding skin. Rationale: A ring of redness on the surrounding skin can indicate underlying infection, and the nurse should report any indication of infection such as purulent drainage, swelling, warmth, or strong odor. A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? ---------- Correct Answer ---------- *Absence of breath sounds Rationale: A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due to partial or total collapse of the lung. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Peripheral edema Rationale: Peripheral edema is caused by weakness in the right side of the heart, allowing blood to back up into the venous system and leak into interstitial tissues. A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Encourage the client to drink a carbonated beverage 1 hr before meals. Rationale: The nurse should instruct the client to drink a carbonated beverage 1 hr before or after meals to reduce the risk for nausea A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions

should the nurse take? ---------- Correct Answer ---------- *Irrigate the catheter as prescribed. Rationale: The nurse should irrigate the catheter to remove blood clots and maintain catheter patency. A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? -- -------- Correct Answer ---------- * "I will take a stool softener until my eye is healed." Rationale: The client should avoid straining during bowel movements to prevent an increase in intraocular pressure. A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? ---------- Correct Answer ---------- *Hypertension Rationale: Hypertension is an early manifestation of increased intracranial pressure. Other manifestations include restlessness, headache, and change in level of consciousness. The nurse should monitor and report manifestations of increased intracranial pressure. A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Encourage the client to drink 8 glasses of water a day. Rationale: The nurse should instruct the client to drink 6 to 8 glasses of noncaffeinated beverages to thin bronchial secretions. A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? ---------- Correct Answer ---------- *Airway obstruction Rationale: Burns to the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This kind of damage can result in severe respiratory difficulty. A burn to the chest may limit expansion of the thoracic cage, resulting in impaired breathing. Therefore, using the airway, breathing, circulation (ABC) priority-setting framework nursing measures to maintain airway patency are the priority nursing actions. A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? ---------- Correct Answer ---------- *An expanding circular rash

Rationale: Early Lyme disease is characterized by fever, flu-like manifestations, and erythema migrans, an expanding circular (bull's-eye) rash that often develops at the bite site. A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? ---------- Correct Answer ---------- *Combing her hair Rationale: The nurse should recognize that combing the hair requires abduction of the arm. This movement is avoided for the client who is in the immediate postoperative period until the drains have been removed. Activities requiring abduction and rotation of the shoulder may resume following healing of the surgical site. A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Report of dryness with vaginal intercourse Rationale: Perimenopause includes the years surrounding menopause. During this time the ovaries produce less estrogen, and a woman's menstrual periods cease. Because of the changes in the vagina, some women may have dryness, discomfort, or pain during vaginal intercourse. A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? ---------- Correct Answer ---------- *Three to seven days after menses stops Rationale: The client should plan to perform breast self-examination about 3 to 7 days after menstruation, when the breasts are least tender and not engorged. A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? ---------- Correct Answer ---------- *Turkey and cheese sandwich with scalloped potatoes Rationale: This menu choice is composed primarily of complete, high-quality proteins and large quantities of carbohydrates. Therefore, the nurse should recommend this selection to meet the prescribed dietary regime. A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? ---------- Correct Answer ---------- *Take a laxative the evening before the procedure.

Rationale: Stool or gas in the bowel may make it difficult to visualize the renal system during an intravenous pyelogram, so typically the bowel is cleansed the day before. A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease? ---------- Correct Answer ---------- * "I feel so much better after eating." Rationale: A client who has peptic ulcer disease usually experiences pain when the stomach is empty, 2 to 3 hr after meals or in the middle of the night. It is usually relieved by eating. A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? ---------- Correct Answer ---------- *Schedule pain medication on a routine basis. Rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's safety and security needs. By scheduling the client's pain medication on a routine basis, the nurse can prevent acute pain exacerbations. The nurse is contributing to the plan of care for a client who is 4 hr postoperative following a vaginal hysterectomy. Which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ---------- *Provide tub baths for perineal comfort. Rationale: The nurse should provide frequent perineal care to minimize skin breakdown and the possibility of infection to the client who has had a vaginal hysterectomy; however, tub baths are contraindicated until vaginal bleeding has stopped. A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? ---------- Correct Answer ---------- * "I should call the clinic before taking any over-the-counter medications." Rationale: Taking over-the-counter medications that dilate the pupil could cause the client who has chronic open angle glaucoma to experience an increase in intraocular pressure. The nurse should instruct the client to always check with the provider before using over-the-counter medications. A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---------- *Flush the tube with 30 mL of water every 4 hr. Rationale: The nurse should flush the gastrostomy tube with 30 to 60 mL of water every four hours to provide free water to the client and prevent dehydration

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube? ---------- Correct Answer ---------- *Instruct the client to place his chin to his chest and swallow. Rationale: The nurse should instruct the client to place his chin to his chest and swallow to facilitate insertion of the nasogastric tube after it reaches the oropharynx. This position directs the tube toward the posterior pharynx and esophagus rather than the larynx and the bronchus. The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take? -------- -- Correct Answer ---------- *Maintain the drainage container below the level of the client's chest. Rationale: Keeping the drainage collection container below the level of the client's chest prevents the back-flow of fluid into the client's chest. A nurse is collecting data from a client who has a right hemothorax and a water-seal chest tube drainage system to closed suction. For which of the following findings should the nurse contact the charge nurse? ---------- Correct Answer ---------- *Subcutaneous emphysema is present on the client's right chest wall. Rationale: The presence of subcutaneous emphysema is indicative of an air leak between the lung and the chest tube and should be reported to the charge nurse. A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan? ---------- Correct Answer ---------- *Monitor oral mucosa daily. Rationale: The client who has bone marrow suppression experiences a decrease in erythrocytes, platelets, and leukocytes. The decrease in WBCs places the client at risk for the development of opportunistic infections; therefore, the nurse should monitor the client's oral mucosa daily for the development of sores or white patches and offer frequent oral care. A nurse is collecting data from an older adult client who is preoperative for a total hip arthroplasty. For which of the following findings should the nurse notify the provider? ---- ------ Correct Answer ---------- *The client has an abscessed tooth. Rationale: The nurse should assess for and report any sign of infection in the preoperative client as this increases the risk of surgery and postoperative surgical site infection.

A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Allow the client to keep her hearing aids in. Rationale: The nurse should allow the client to retain possession of her hearing aids so that she will be able to hear and understand instructions given to her. The nurse should notify the surgical team and place a note on the front of the chart and the pre-operative checklist indicating that hearing aids were left in. The nurse is assisting with the care of a client who is postoperative following a bowel resection and just arrived to the unit from PACU. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Remove the anti-embolic stockings for 20 min. every 8 hr. Rationale: The nurse should frequently check the anti-embolic stockings and sequential compression devices to ensure they fit appropriate and the compression devices are working. These improve the venous return of blood from the legs and prevent stasis in the lower extremities which helps prevent the development of deep vein thrombosis. The stockings should be removed for 20 min every 8 hr to allow the circulation of air to the skin and for the nurse to perform a full skin assessment. The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching? ---------- Correct Answer ---------- *Baked turkey and salad Rationale: The nurse should reinforce that skinless poultry that is baked, not fried, is a good food choice that is high in protein yet low in fat. The salad provides a serving of vegetables and is a healthy choice provided the salad dressing is also low in fat and sugar. A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestation of this condition to the nurse? ---------- Correct Answer ---------- *Increased urine output Rationale: Diabetes insipidus is a water metabolism disorder caused by a deficiency of antidiuretic hormone (ADH). This deficiency results in the excretion of large amounts of dilute urine. Dehydration and shock may ensue, resulting in a life-threatening situation for the client. A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound? ---------- Correct Answer ---------- *Granulation tissue on the surface of the wound Rationale: As the wound heals, the nurse should expect the wound base to become redder as granulation tissue lines the surface of the wound. Therefore, this is an

expected finding. The vacuum-assisted closure device assists in wound closure by applying a localized negative pressure to draw the edges of the wound together. The device consists of a suction tube embedded in a foam dressing. The foam dressing is applied to the wound bed and sealed in place with an occlusive dressing. The suction is then attached to the vacuum unit, causing the foam to collapse and resulting in drainage of excess fluids, and increasing circulation to the wound bed. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action? ---------

• Correct Answer ---------- *Prevent aspiration. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine the priority action is to prevent aspiration. Since the client's jaws are wired together, aspiration is a risk if the client vomits. Therefore, the client should receive medication for nausea, as indicated, and wire cutters and suction are kept at the bedside at all times in case of vomiting or difficulty breathing. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- *Hardened skin Rationale: Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and subcutaneous tissues, the distal extremities stiffen and lose mobility. It can also cause disorders of the heart, lungs and kidneys. A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take? ---------- Correct Answer ---------- *Add thickener to fluids. Rationale: The nurse should thicken fluids to make them easier to swallow and prevent aspiration. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client? ---------- Correct Answer ---------- *Airway obstruction Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk to this client is airway obstruction. Burns in this area can involve damage to the upper airway, resulting in swelling and respiratory compromise. The nurse should monitor the client for manifestations of respiratory distress. A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? ---------- Correct Answer ---------- *Take the medication 45 minutes before eating.

Rationale: The nurse should instruct the client to take the medication before eating to allow the medication time to work and limit difficulty chewing and swallowing. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? ---------- Correct Answer ---------- *Hypotension Rationale: The client who has diabetes insipidus produces excessive urine resulting in hypovolemia and hypotension. The nurse should monitor the client for hypotension and dehydration. A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess - 2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make? ---------- Correct Answer ------ ---- *Respiratory acidosis Rationale: The nurse should identify the client who has respiratory problems such as obstruction or depression of the respiratory system as at risk for the development of respiratory acidosis. The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic. The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the results is that the client is in respiratory acidosis. A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching? ---------- Correct Answer ---------- * "I will wear stockings with elastic tops." Rationale: The nurse should reinforce with the client to avoid constrictive clothing that can impair circulation. A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take? ---------- Correct Answer --- ------- *Calmly ask the client if he would like to listen to some music. Rationale: The nurse should remain calm to avoid agitating the client further. By offering to play music, the nurse may be able to distract the client and then reintroduce the idea of morning care. A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following? ---------- Correct Answer ---------- *Granulation tissue