NURSING 102 Med Surge Final Exam plus RATIONALES (100% CORRECT Answers) Questions and Answers | Guaranteed Pass

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Med Surge Final Exam 1…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? Amylase Ra... tional Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days. 2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? Dysmenorrhea that is unresponsive to NSAIDs. Rational Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period but can cause pain at other times in the cycle. The discomfort is often unrelieved by the use of NSAIDs. 3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Establish a plan of care with the client that sets attainable goals. Rational The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable 4….A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? Large incisions will be made in the eschar to improve circulation. Rational An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. 5….A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Dark and foamy Rational The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood. 6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? Erythrocyte sedimentation rate (ESR) Rational Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases. 7….A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day. Rational The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation. 8….A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? Excessive thrombosis and bleeding Rational The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways. 9….A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? Postmenopausal bleeding Rational Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. 10…A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Hypercholesterolemia Hypertension Obesity Smoking 11…A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environment Rational A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. 12…A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.) Assess blood glucose level Assess for neck vein distention Incorrect. Monitor for an irregular heart rate Incorrect. Monitor for postural hypotension Weigh the client daily 13…A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Sedentary lifestyle Incorrect. Obesity Aging Caffeine intake Secondhand smoke Sedentary lifestyle is correct. Immobility depletes bone. Obesity is incorrect. Women who are obese have a greater capacity for storing estrogen to help maintain acceptable levels of calcium. Aging is correct. Women lose bone due to estrogen depletion after menopause. Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine. Secondhand smoke is correct. Smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking. 14…A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? Sputum culture for acid-fast bacillus Rational Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis. 15…A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) Dyspnea Incorrect. Bradycardia Barrel chest Clubbing of the fingers Incorrect. Deep respirations Rational Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial- oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 16…A nurse in an emergency room is caring a the client who sustained partial- thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? Inspect the mouth for signs of inhalation injuries. Rational Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time 17…A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? Fresh flowers and potted plants in the room 18…A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? Avoid foods high in fat. Rational The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic. A client who has chronic cholecystitis has intolerance to fatty foods 19…A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? Instruct the client about the use of a sequential compression device. Rational The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication. 20…A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? Dryness with intercourse Rational Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse 21…During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? Basal cell carcinoma Rational A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration. 22…A nurse is teaching a group of newly license nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? Ask about the client's exposure to any past or present STIs. Rational The nurse should assess the client exposure to any past or present STIs and any treatment taken. 23…A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? Practice effective hand hygiene. Rational Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A. 24…A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) Increased heart rate Increased blood pressure Increased respiratory rate Incorrect. Increase hematocrit Incorrect. Increased temperature Rational Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 25…A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? It is caused by the lack of production of aldosterone by the adrenal gland. Rational Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland 26…FLAG A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? Do not apply heat to the area of irradiation. Rational This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation. 27…A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching? A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. Rational CA 125 tests are useful in monitoring progress during and after treatment of ovarian cancer 28…A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A non-healing sore Incorrect. Bloating Change in bowel pattern Change in moles Nagging cough 29…A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? Heart rate Rational When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement 30…A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects? Bleeding from the gums Rational Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets. 31…A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? Cold and numb numbness distal to the fistula site Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider. 32…A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? Basal cell carcinoma has a low incidence of metastasis. Rational Basal cell carcinoma is a localized lesion that seldom metastasizes. 33…A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? As soon as the nurse can prepare the client and the administration set Rational The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr. 34…A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? Rest frequently throughout the day. Rational Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands. 35…A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? CD4-T-cell count 180 cells/mm3 Rational A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider 36…A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? I will eat foods that are served at room temperature. Rational The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea. 37…A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Rational The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. 38…A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider? Musculoskeletal pain Rational The client who is experiencing musculoskeletal pain should notify the provider. Musculoskeletal pain is a common adverse effect that affects 50% of clients that is possibly caused from estrogen deprivation 39…A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? Decreased serum calcium level Rational A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. 40…A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? Poor Rational At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages. 41…A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? Artificial lubrication can be used to treat vaginal itching and dryness. Rational The nurse should instruct the client that atrophic vaginal changes occur due to the loss of estrogen postoperatively and can also cause pain and dryness during sexual intercourse. Artificial lubricants can reduce the manifestations associated with diminished mucous production. 42…A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Rational A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. 43…A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Thyroid hormones Rational Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss. 44…A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching? The urethral orifice is assessed by separating the labia minora. Rational The urethral orifice, clitoris, and vaginal orifice are examined for lesions, inflammation, and discharge by separating the labia minora. 45…FLAG A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Rational Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. 46…A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform? Hold the wrist at a 90-degree flexion. Rational Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the hand and wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90-degree flexion will usually result in numbness, tingling, or weakness 47…A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? Avoid foods prepared with tap water. Rational To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water. 48…A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? Feces can be present in the vagina. Rational The presence of feces in the vagina is a manifestation of a genital fistula. This statement indicates a need for further teaching. 49…A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? Cover the wound with a moist, sterile gauze dressing. Rational The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing 50…A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serosanguineous Rational Watery red drainage should be documented as serosanguineous. 51…A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? Before the examination, your provider will give you a sedative that will make you sleepy. Rational This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. 52…A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? I will reduce my intake of vitamin K-rich foods. Rational Vitamin K is necessary for bone health. The nurse should instruct the client to increase her intake of vitamin K-rich foods—such as green, leafy vegetables—to promote bone health 53…A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? Oncology nurse Rational The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion. 54…A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner. Rational The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort 55…A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? Reduce the client's intake of protein. Rational Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended. 56…A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Cheyne-Stokes respirations Rational Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death). 57…A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be Dysphagia. Rational Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness 58…A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three- chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? Verify that the suction regulator is on and check the tubing for leaks. Rational A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing. 59…A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures? Your pain will gradually become less severe. Rational Phantom leg pain usually diminishes over time, and often is intermittent in response to a trigger. 60…A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations? Developing breast cancer Rational The BRCA1 gene is used to determine the probability of a client developing breast cancer. BRCA1 genetic testing is used for women who have a strong family history of breast cancer 61…A nurse is planning a teaching session about hysterosalpingography for a client who has a diagnosis of infertility. The nurse should include which of the following information in the teaching plan? The client might experience shoulder pain following the procedure. Rational Shoulder pain can occur due to phrenic nerve irritation cause by the contrast media. 62…A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? History of breast cancer Rational Women with a history of breast cancer should be counseled against using HT. 63…A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care? Limit the number of health care workers entering the room. Rational The nurse should limit the number of health care workers entering the client's room to prevent possible overexposure to microorganisms that can lead to an infection. 64…A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions? Prevent the spread of infection with good household cleaning practices. Rational The client should follow standard precautions and use a 1:10 solution of bleach to disinfect areas that come into contact with blood and body fluids. 65…A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has gastroenteritis and is febrile. Rational This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit. 66…A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? Performing the procedure independently Rational The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home 67…A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? Check the results of the client's most recent CBC Rational The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher. 68…A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? DIC is caused by abnormal coagulation involving fibrinogen. Rational DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage. 69…A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? Completing a dressing change Rational Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids 70…A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching? Postcoital bleeding may occur. Rational The client may experience postcoital bleeding, because the polyps are soft, fragile, and bleed when touched. 71…A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include? It is primarily transmitted through direct contact with infected body fluids. Rational The nurse should include in the teaching that HIV is transmitted through direct contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid, breast milk and other body fluids 72…A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment? Fatigue Rational The nurse should inform the client to expect fatigue with her radiation treatment. Fatigue occurs regardless of the radiation target site. 73…A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paraplegia Rational Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1. 74…A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? MRI of the chest Rational A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction. 75… A nurse is reviewing laboratory values for a client who has systemic lupus erythematous (SLE). Which of the following values should give the nurse the best indication of the client's renal function? Serum creatinine Rational A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function. 76…A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) Incorrect. Bacteria Incorrect. Diuretics Aging Obesity Smoking Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which does not cause irreversible damage to joints. Infection is not a risk factor for osteoarthritis. Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for osteoarthritis. Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time. Smoking is correct. Smoking is a risk factor for osteoarthritis, as smoking predisposes people to the loss of cartilage in the knees. 77… A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Pantoprazole 80 mg IV bolus twice daily Rational The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions 78… A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? Output of burgundy colored urine Rational Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter. 79…A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg Rational The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg. 80…A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken- Blakemore tube to control the bleeding. Which of the following actions should the nurse take? Provide frequent oral and nares care. Rational A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions. 81…A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? It facilitates the client's deep breathing 82… A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms? Flu-like symptoms and night sweats Rational The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection. 83… A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? Obtain a sputum culture Rational The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia 84…A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? Perform a 12-lead ECG Rational The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction. 85… A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? I should expect the hospice team to help me manage my dyspnea. Rational Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness. 86…A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? The client will walk for 30 min 5 days a week. Rational CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week. 87…A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? Defibrillation Rational The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm. 88…A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? Elevated central venous pressure (CVP). Rational CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure 89…A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 Rational With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis. 90…A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication? Bradycardia Rational Atenolol is a beta-blocker, which slows the heart rate. The nurse should instruct the client to monitor his pulse rate and report bradycardia. 91…While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? Discontinue the existing IV line Rational The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line. 92…A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.) Troponin I Troponin T Incorrect. Plasma low-density lipoproteins CPK Myoglobin 93…A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Keep the drainage system below the level of the client's chest at all times. Rational During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity 94…A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Continue to monitor the client. Rational The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube. 95…A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serosanguineous 96…A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-colesterol diet. Which of the following food choices by the client indicates the need for further teaching? A slice of cheese Rational The client should limit the intake of cheese due to high levels of fat and sodium. 97…A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? Lethargy Rational A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion. 98…A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? Check the client's vital signs every hour during the transfusion. Rational The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction. 99…A nurse is planning to teach a client about a lowpotassium diet. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) Incorrect. Butter Incorrect. Poultry Correct. Yogurt Incorrect. Frozen vegetables Correct. Orange juice 100..A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? WBC count Rational An elevation in the WBC count (leukocytosis) indicates that the client’s immune system is defending him against the pathogens causing an infection. 101..A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Atropine Rational The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable. Epinephrine The team administers epinephrine during cardiopulmonary resuscitation (CPR) to clients who have asystole or pulseless electrical activity. Magnesium The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of ventricular tachycardia. Sodium bicarbonate The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR. 102..A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Encourage the use of an incentive spirometer Rational Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications. 103..A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? Fresh flowers and potted plants in the room Rational Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed fruits and vegetables. Immunocompromised clients are more susceptible to infection and illness from food-borne bacteria than other clients. 104..A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor? Hypokalemia Rational Hypokalemia is an adverse effect of furosemide 105..A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for? Decreased potassium level Rational Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning 106.. A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply.) Apply pressure to the nares. Place ice to the bridge of the client's nose. Incorrect. Instruct the client to blow his nose. Incorrect. Tilt the client's head backward Move the client into high-Fowler's position. Rational Apply pressure to the nares is correct. Applying direct pressure to the lateral aspects of the nose helps to clot the blood. The nurse should apply firm and consistent pressure for several minutes until coagulation occurs. Place ice to the bridge of the client's nose is correct. Placing an ice pack on the nose causes the blood vessels to vasoconstrict, which decreases bleeding. The nurse should use a barrier, such as a wash cloth, to avoid skin damage from the direct application of ice to the skin. Ice packs should not be left on the skin for longer than 20 min. Instruct the client to blow his nose is incorrect. The nurse should instruct the client to avoid blowing his nose for 24 hr as this can cause dislodgement of clots. The nurse should also discourage coughing, straining, or sneezing as these activities can also cause the blood vessels to weaken, which can trigger rebleeding. Tilt the client's head backward is incorrect. The nurse should tilt the client's body and head forward to decrease the risk for aspiration and swallowing of blood. Move the client into high-Fowler's position is correct. Sitting upright facilitates breathing and decreases the risk for aspiration. 107..A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated? Troponin I 108..A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? I will need to apply electrodes to your chest and extremities. Rational The nurse should inform the client that she will apply small electrodes to the client's chest and extremities before conducting the test. These electrodes transmit electrical current and allow for the recording of the heart's electrical activity 109..A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take? Give the ordered KCL as prescribed. Rational The client's serum potassium level is below the recommended reference range. The nurse should administer the KCL as prescribed. 110.. A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? Apply ice to the affected area. Rational Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling. 111..A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? Different apical and radial pulses. Rational Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading 112..A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? Preoxygenate the client with 100% oxygen for up to 3 min. Rational To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning. 113..A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? Vertigo Rational The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension. 114..A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? Administering a nebulized beta-adrenergic Rational The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation. 115..The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? Carvedilol Rational Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma. 116.. A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? Schilling test Rational The Schilling test helps determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. 117..A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? Adrenocortical insufficiency Rational Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency. 118..A nurse is providing teaching for a client who has hypertension and a prescription change from metoprolol to metoprolol/hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? With the new medication, I should experience fewer side effects. Rational The client has stated an understanding of the purpose of the addition of the hydrochlorothiazide (HCTZ) to the metoprolol dosage. When used in combination with thiazide diuretics, a lower dose of the beta-blocker can be used. The benefit is there are fewer side effects when beta-blockers (and other antihypertensives) are used in lower dosages 119..A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include? Monitor for leg cramps. Rational Hydrochlorothiazide can cause hypokalemia. The client should monitor for manifestations of hypokalemia, such as fatigue, tachycardia, leg cramps, and muscle weakness. 120..A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide? Take the medication early in the day. Rational The nurse should instruct the client to take hydrochlorothiazide early in the day to avoid nocturia. 121..A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? Cardiac dysrhythmias Rational This client’s potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression. 122..A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? I may eat 10 ounces of lean protein each day Rational Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching. 123..A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? Increased anteroposterior diameter of the chest Rational The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs 124..A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching? I'll take this medication once a day in the evening. Rational Montelukast, a leukotriene modifier, is used to prevent asthma exacerbations. The client should take it on a daily basis once a day in the evening 125..A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects? Oral candidiasis Rational Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse her mouth with water 126..A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? I will be sure to take the albuterol before taking the cromolyn. Rational The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs. 127..A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching? Offer fluids to your child multiple times every day Rational Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse should provide the parents with a specific fluid goal for the child to reach each day 128..A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? Generalized urticaria. Rational The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm. 129..A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? Instructing how to use kitchen tools to prepare a meal Rational As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self- management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping 130..A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Agitation Rational The nurse should expect agitation due to neurological changes from poor oxygen exchange. 131.. A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.) Incorrect. Prime the blood tubing with dextrose 5% in water. Incorrect. Transfuse the blood product within 5 hr after removing it from refrigeration. Check the expiration date of the blood product with a second nurse. 132..A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? White coating in the mouth Rational Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider 133…A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? Reposition the client. Rational The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube. 134..A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? Diuretics are the first type of medication to control hypertension. Rational The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure. 135.. The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? Fluctuation of the fluid level within the water seal chamber Rational Fluctuation of fluid within the water seal chamber occurs with inspiration and expiration until the client’s lungs have re-expanded or the system is occluded. 136.. A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? Development of subcutaneous emphysema Rational Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider. 137.. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings? Impaired sense of humor Rational A client who had a stroke involving the left cerebral hemisphere is likely to have language deficits, which include difficult using or comprehending language and difficulty writing. The nurse should expect a client who had a stroke involving the right cerebral hemisphere to have an impaired sense of humor. 138..A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? The client's bladder becomes distended. Rational Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face. 139.. A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? Check the results of the client's most recent CBC. Rational The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher. 140.. A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? The purpose of this device is to immobilize the cervical spine. Rational A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks. 141..A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? Ability to self-feed with the use of adaptive equipment Rational A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment. 142..A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Incorrect. Furnish restraints at the bedside. 143..A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? Place suction equipment at the client's bedside. Rational Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client. 144..A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Place the client in a high-Fowler's position. Rational The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse’s initial action should be to place the client in a high-Fowler’s position to assist in providing immediate reduction in blood pressure and intracranial pressure 145..A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.) Grooming Long-term memory Incorrect. Support systems Affect Incorrect. Presence of pain 146..A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? Assess the cranial nerves. Rational The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hr. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the development of Cushing’s triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction 147..A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? The client opens his eyes when spoken to. Rational A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain. The client can follow simple motor commands. The client's ability to follow commands would require a score of 6 for best motor response. The client is unable to make vocal sound. The inability of the client to make vocal sounds would result in a score of 1 for best verbal response. The client is unconscious. The unconscious client would have a score of 1 for eye opening and a 1 for best verbal response. 148.. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has gastroenteritis and is febrile. Rational This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit. 149..A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching? I'll be glad when I can stop taking this medicine. Rational Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider. 150.. A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.) Confusion Incorrect. Tachycardia Incorrect. Hypotension Nonreactive dilated pupils Slurred speech 151..A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? Bradykinesia Rational The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease. 152.. A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? Use contraception while taking this medication. Rational Sumatriptan can cause teratogenesis and should not be used during pregnancy. 153.. A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? Implement a schedule to include periods of rest. Rational The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination. 154..A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Incorrect. Neck pain and stiffness Slurred speech Pupillary changes Disorientation Rational Headache is correct. A client who has increasing ICP might manifest a headache. Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion. 155.. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Bradycardia Increased ICP from TBI: Cushing's triad: severe hypertension, bradycardia, widened pulse pressure 156.. A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? Dopamine Rational Dopamine increases output by strengthening force of contractions) 157..A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? Report of a night cough 158.. A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism. Dyspnea 159.. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to the affected joints. 160.. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity 161.. A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity? Bradycardia 162.. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? Apply firm pressure to the insertion site 163.. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re- expansion? Bubbling in the water-seal chamber has ceased. 164.. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? Hypoactive bowel sounds 165.. nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? Regular insulin (fast acting) 20 units IV bolus Can be effective within 10 mins Management: hydrate, correct acid-base imbalance (metabolic acidosis), & decrease BGL) 166.. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment? Decreased viral load 167.. A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? Hypotension 168.. A nurse is caring for a client who is eight hours post-operative following a total hip arthroplasty the client is unable to void on the bed pan Which of the following actions should the nurse take first Scan the bladder with a portable ultrasound Rational The first action should be using the nursing process which is assisting the client scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder 169.. A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching ? This device can detect when you have an irregular heart rate Rational Because Holter reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded. 170.. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? Remove the catheter and insert another into a different site. Rational It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere. 171.. A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? Decreased serum calcium level Rational A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. 172.. A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? Fever Rational 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. 173.. A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? Dryness with intercourse Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse. 174.. A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? Hemolytic 175..A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? Serum creatinine Rational A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function. 176.. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.) Blurred vision Tachycardia Moist, clammy skin 177.. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg Rational The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg. 178.. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? Check the client's vital signs. Rational It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm. 179.. A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? Exercise Rational Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest. 180.. A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? CD4-T-cell count 180 cells/mm3 Rational A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider. 181.. A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? The area surrounding the insertion site feels warm to the touch. 182.. A community health nurse is developing a pamphlet about breast self- examination (BSE) for a local health fair. Which of the following instructions should the nurse include? Breasts can be examined in the shower with soapy hands. The nurse should encourage clients to perform a BSE or do an extra examination while showering. This allows clients to concentrate more easily on feeling for tissue changes. 183.. A nurse is caring for four clients. Which of the following clients is at greatest risk for a pulmonary embolism. A client who is 12 hr postoperative following a total hip arthroplasty 184.. nurse is assessing a client with diabetes insipidus. The nurse knows that which assessment finding is typical of this condition? Polyuria 185.. A nurse is caring for a client after a craniotomy for pituitary tumor who has developed diabetes insipidus. The client is receiving vasopressin (Pitressin). The desired response to the medication is evident when the nurse observes which of the following findings? A decrease in urine output. Rational The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Pitressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insipidus. A decreased urine output is the desired response. 186.. A nurse in a providers office is reviewing lab results of a client who is being evaluated for secondary hypothyroidism. Which of the following lab findings is expected for a client who has this condition? Decreased serum T3 187.. A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy INR 2.5 188..A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? Void before and after intercourse 189.. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider? Crackles heard on auscultation 190.. A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching? I'll call my doctor if I notice any unusual menstrual bleeding. 191.. A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? Tingling feeling in the extremities Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities. 192.. A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? Do not apply heat to the area of irradiation. Rational This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation. 193.. A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.) Diaphoresis Coarse facial features Enlarged distal extremities is correct. Muscle weakness is correct. Diaphoresis Acromegaly is a chronic metabolic disorder caused by an excess of growth hormone after normal growth of the skeleton and other organs is complete. The physical manifestations associated with acromegaly include enlarged sebaceous glands with excessive sweating. Coarse facial features is correct. The physical manifestations associated with acromegaly include enlarged facial bones with thickening of the skin, leading to coarse facial features. Enlarged distal extremities is correct. The physical manifestations associated with acromegaly include enlarged hands and feet with thickening of the skin. Muscle weakness is correct. The physical manifestations associated with acromegaly include fatigue and muscle weakness. 194.. A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? Arterial blood gases Rational According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases. 195.. A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. 196.. A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A nonhealing sore Incorrect. Bloating Change in bowel pattern Change in moles Nagging cough 197.. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? a self-report pain rating scale 198.. A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? Visual acuity Rational A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals. 199.. A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching? Postcoital bleeding may occur. Rational The client may experience postcoital bleeding, because the polyps are soft, fragile, and bleed when touched. 200.. A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching? I'll call my doctor if I notice any unusual menstrual bleeding. 201.. A nurse is teaching a client who has vulvodynia about self-care measures to alleviate symptoms. Which statement by the client indicates an understanding of the teaching? I should avoid the use of any lubricants Rational The nurse should recommend the use of natural oils such as olive oil for lubricant and avoid lubricants containing propylene glycol. "I should wear cotton undergarments." White cotton underwear is recommended for the client with vulvodynia. 202.. A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? It is caused by the lack of production of aldosterone by the adrenal gland. Rational Addison's disease is caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland. "It is caused by the overproduction of growth hormone by the pituitary gland." A client who has an overproduction of the growth hormone has acromegaly. "It is caused by the overproduction of parathormone by the parathyroid gland." A client who has hyperparathyroidism produces an excessive amount of parathormone. 202.. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Encourage fluid intake at and between meals. Rational Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury. 203.. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? Administer oxygen via nasal cannula. Rational The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues. 204.. A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? DIC is caused by abnormal coagulation involving fibrinogen. Rational DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage. 205.. A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? Drink 3 L of fluid every day. Rational The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation. 206..A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? History of breast cancer Rational Women with a history of breast cancer should be counseled against using HT. 207..A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? Scatter rugs are present in the kitchen. Rational Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision. 208.. A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment? Fatigue Rational The nurse should inform the client to expect fatigue with her radiation treatment. Fatigue occurs regardless of the radiation target site. Alopecia Alopecia is an acute adverse effect of radiation to the brain. Diarrhea Diarrhea is an acute adverse effect of radiation to the abdomen and pelvis. 209.. After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions? Apply hydrating lotions. Rational The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume. 210.. A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? Fever Rational 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. 211.. A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? Hip arthroplasty Rational Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively. 212.. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? Output of burgundy colored urine Rational Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. S 213.. A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion? Temperature Rational The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority action is to take a baseline temperature measurement. The nurse should then monitor the client's temperature throughout the infusion as an increase in temperature can indicate an adverse reaction. 214.. A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report? Having a decreased ability to perceive colors. Rational Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors. 215.. A nurse is evaluating a client's laboratory results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of the following diagnoses? Prostatic cancer 216.. A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? draining blood and fluid from the pleural space 217.. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make? Herpes zoster is not contagious to people who have had chickenpox 218.. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? check the clients capillary blood glucose level every 4 hr [Show More]

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