NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS

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NCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERSNCLEX-SELECT ALL THAT APPLY-QUESTIONS AND ANSWERS 1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following labora... tory tests assesses coagulation? Select all that apply. 1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count. 4. Hemoglobin 5. Complete Blood Count 6. White Blood Cell Count Answer: 1, 2, and 3 Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies. The hemoglobin level, though important information prior to an invasive procedure like liver biopsy, does not assess coagulation. 2. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 1. Weight loss. 2. Increased clotting time. 3. Hypertension. 4. Headaches. Answer: 2, 3, and 4 Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera. Page 1 3. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 2. Head is tilted down while inhaling the medication 3. Client waits 5 minutes between puffs. 4. Mouth is rinsed with water following administration 5. Client lies supine for 15 minutes following administration. Answer: 1 and 4. 4. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply. 1. Hearing loss 2. Visual disturbance 3. Headache 4. Orthopnea 5. Gout 6. Weight loss Answers: 2, 3, 4 and 5. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera. Page 2 5. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds 2. Auscultation of bowel sounds 3. Presence of chest pain. 4. Presence of peripheral edema 5. Color of nail beds Answer: 1, 3, 5. A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia. 6. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. 1. “I will need to dispose of my old clothing when I return home.” 2. “I should always cover my mouth and nose when sneezing.” 3. “It is important that I isolate myself from family when possible.” 4. “I should use paper tissues to cough in and dispose of them properly.” 5. “I can use regular plate and utensils whenever I eat.” Answer: 2, 4, 5. Page 3 7. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. 1. Thirst 2. Palpitations 3. Diaphoresis 4. Slurred speech 5. Hyperventilation Answer: 2, 3, 4. Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed. 8. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply: 1. Sweating 2. Low PCO2 3. Retinopathy 4. Acetone breath 5. Elevated serum bicarbonate Answer: 2, 4. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis. Page 4 9. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. 1. Assessing the client’s bowel sounds 2. Providing skin care following bowel movements 3. Evaluating the client’s response to antidiarrheal medications 4. Maintaining intake and output records 5. Obtaining the client’s weight. Answer: 2, 4, and 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated. 10. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. 1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. 2. Activity intolerance related to increased cardiac output. 3. Decreased cardiac output related to structural and functional changes. 4. Impaired gas exchange related to decreased sympathetic nervous system activity. Answer: 1 and 3. HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion Page 5 because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity. 11. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. 1. Verify patency of the line by the presence of a blood return at regular intervals. 2. Inspect the insertion site for swelling, erythema, or drainage. 3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. 4. If unable to aspirate blood, reposition the client and encourage the client to cough. 5. Contact the health care provider about verifying placement if the status is questionable. Answer: 1, 2, 4, 5. A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. 12. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with the parents, which information would the nurse expect to be included in the client’s history? Select all that apply. Page 6 1. Impulsiveness 2. Lability of mood 3. Ritualistic behavior 4. psychomotor retardation 5. Self-destructive behavior 13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which of the following assessment data is the nurse also likely to find? Select all that apply. 1. The client functions well in other areas of his life. 2. The degree of aggressiveness is out of proportion to the stressor. 3. The violent behavior is most often justified by the stressor. 4. The client has a history of parental alcoholism and chaotic, abusive family life. 5. The client has no remorse about the inability to control his anger. Answer: 1, 2, 4. A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior generally functions well in other areas of his life. The degree of aggressiveness is typically out of proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and guilt for the aggressive behavior. 14. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. Apply continuous passive motion machine during day. 2. Perform neurovascular checks. 3. Elevate head of bed 30 degrees before meals. 4. Change dressing once a shift. Page 7 Answer: 3. It is specific in what to do and when. 15. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take. 1. Place the client in good body alignment 2. Check the level of the drainage bag 3. Contact the physician 4. Check the peritoneal dialysis system for kinks 5. Reposition the client to his or her side. Answer: 1, 2, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client’s position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. 16. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply. 1. Excess Fluid Volume 2. Imbalanced Nutrition; Less than Body Requirements 3. Activity Intolerance 4. Impaired Gas Exchange 5. Pain. Page 8 Answer: 1, 2, 3. Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure. 17. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1. Head tilt 2. Vomiting 3. Polydipsia 4. Lethargy 5. Increased appetite 6. Increased pulse Answer: 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor. 18. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis Page 9 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication 6. Place the client in a supine position with legs elevated Answer: 1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most lifethreatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia. 19. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. 1. “If I limit my fluid intake I will not have to empty my ostomy pouch as often.” 2. “I can place an aspirin tablet in my pouch to decrease odor.” 3. “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.” 4. “I must use a skin barrier to protect my skin from urine.” 5. “I should empty my ostomy pouch of urine when it is full.” Answer: 3, 4. The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000 ml per day and should not limit intake. Adequate fluid Page10 intake helps to flush mucus from the ileal conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine. An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin. 20. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. 1. Uterine enlargement 2. Fetal heart rate detected by nonelectric device 3. Outline of the fetus via radiography or ultrasound 4. Chadwick’s sign 5. Braxton Hicks contractions 6. Ballottement Answers: 1, 4, 5, and 6. The probable signs of pregnancy include: • Uterine Enlargement • Hegar’s sign or softening and thinning of the uterine segment that occurs at week 6. • Goodell’s sign or softening of the cervix that occurs at the beginning of the 2nd month • Chadwick’s sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. • Ballottement or rebounding of the fetus against the examiner’s fingers of palpation • Braxton-Hicks contractions • Positive pregnancy test measuring for hCG. Positive signs of pregnancy include: Page11 • Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks • Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG • Active fetal movement palpable by the examiners • Outline of the fetus via radiography or ultrasound 21. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? 1. Elevated blood pressure 2. Negative urinary protein 3. Facial edema 4. Increased respirations Answer: 1 and 3. The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia. 22. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. 1. Monitor maternal vital signs every 2 hours 2. Notify the physician if respirations are less than 18 per minute. 3. Monitor renal function and cardiac function closely 4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose 5. Monitor deep tendon reflexes hourly 6. Monitor I and O’s hourly 7. Notify the physician if urinary output is less than 30 ml per hour. Page12 Answers: 3, 4, 5, 6, and 7. When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys. 23. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. 1. Reflects electrical impulse beginning at the SA node 2. Indicated electrical impulse beginning at the AV node 3. Reflects atrial muscle depolarization 4. Identifies ventricular muscle depolarization 5. Has duration of normally 0.11 seconds or less. Answer: 1, 3, 5. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height. 24. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. 1. Verify patency of the line by the presence of a blood return at regular intervals. 2. Inspect the insertion site for swelling, erythema, or drainage. 3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. Page13 4. If unable to aspirate blood, reposition the client and encourage the client to cough. 5. Contact the health care provider about verifying placement if the status is questionable. Answer: 1, 2, 4, 5. A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen. 25. To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.) 1. Drinking a glass of wine just before retiring to bed 2. Eating a large meal 1 hour before bedtime 3. Consuming a small glass of warm milk at bedtime 4. Performing mild exercises 30 minutes before going to bed Answer: 3. A small glass of milk relaxes the body and promotes sleep. 26. The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): 1. Extended time to fall asleep 2. Falling asleep at inappropriate times Page14 3. Difficulty staying asleep 4. Feeling tired after a night’s sleep Answer: 1, 3, and 4. These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia. 27. The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply): 1. Prone 2. Side-lying 3. Supine 4. Fowler’s Answer: 2 and 3. Research demonstrate that the occurrence of SIDS is reduced with these two positions. 28. A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply: 1. Chronic stress 2. Severe anxiety 3. Generalized pain 4. Excessive caffeine 5. Chronic depression 6. Environmental noise Page15 Answer: 1, 4, and 6. Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia. 29. Select all that apply to the use of barbiturates in treating insomnia: 1. Barbiturates deprive people of NREM sleep 2. Barbiturates deprive people of REM sleep 3. When the barbiturates are discontinued, the NREM sleep increases. 4. When the barbiturates are discontinued, the REM sleep increases. 5. Nightmares are often an adverse effect when discontinuing barbiturates. Answer: 2, 4, and 5. Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares. 30. Select all that apply that is appropriate when there is a benzodiazepine overdose: 1. Administration of syrup of ipecac 2. Gastric lavage 3. Activated charcoal and a saline cathartic 4. Hemodialysis 5. Administration of Flumazenil Answer: 2, 3, and 5. Page16 If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation. 1. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. 1. Restrict all visitors. 2. Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. 4. Encourage the consumption of fresh fruits and vegetables. 5. Perform meticulous hand washing before caring for the child. 6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water. Answer: 2, 3, and 5. For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a lowbacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child’s room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy). Page17 2. A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply. 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3. Gabapentin (Neurontin) 4. Ethosuximide (Zarontin) 5. Carbamazepine (Tegretol) 6. Methylphenidate (Ritalin) Answers: 3, 4, and 5. Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety. 3. A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate? 1. Enteric precautions 2. Neutropenic precautions 3. No precautions are required as long as antibiotics have been started. 4. Isolation precautions for at least 24 hours after the initiation of antibiotics Answer: 4. Page18 Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun and maintained for at least 24 hours after antibiotics are given. Options 1, 2, and 3 are incorrect. 4. A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply. 1. Monitor intake and output. 2. Monitor vital signs. 3. Maintain sodium-reduced diet. 4. Monitor electrolyte levels. 5. Increase water intake orally. 6. Administer sodium replacements. Answers: 1, 2, 3, 4, and 5. Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. 5. A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse’s appropriate action is to: 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements. Page19 Answer: 4. The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression. 6. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply. 1. Jewelry will need to be removed. 2. An informed consent will need to be signed. 3. A trained x-ray technician performs the procedure. 4. The procedure will take approximately 45 minutes. 5. A liquid diet can be consumed on the day of the procedure. 6. Solid food intake needs to be restricted only on the day of the procedure. Answer: 1, 2, and 4. Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required because the procedure is invasive and is therefore performed by the health care provider. The client will need to remove jewelry and metal objects from the chest area. The client is also told that pretest medications may be prescribed for relaxation. 7. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply. 1. Ataxia 2. Sedation 3. Constipation Page20 4. Bleeding gums 5. Hyperglycemia 6. Decreased platelet count Answers: 3, 4, 5, and 6. Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can elevate when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines. 8. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone (ADH) Answers: 1, 2, 4, and 6. Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate Page21 institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal. 9. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone (ADH) Answers: 1, 2, 4 and 6. Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal. 10. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client’s temperature Page22 3. Checking the strength of peripheral pulses 4. Obtaining information about the client’s respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease Answers: 1, 2, and 4. A focused data collection process focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client’s complaints. A musculoskeletal and neurological examination also is not related to this client’s complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment. 11. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply. 1. Skin 2. Kissing 3. Inhalation 4. Gastrointestinal 5. Direct contact with an infected individual 6. Sexual contact with an infected individual Page23 Answers: 1, 3, and 4. Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person. 12. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following? 1. “We will be sure to not leave hot liquids unattended.” 2. “I guess my child needs to understand what the word ‘hot’ means.” 3. “We will be sure that our child stays in his room when we work in the kitchen.” 4. “We will install a safety gate as soon as we get home so that our child can’t get into the kitchen.” Answer: 1. Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Options 2, 3, and 4 do not reflect an adequate understanding of the principles of safety. 13. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. Page24 3. Nursing staff are led by a nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients. Answer: 3. In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing. 14. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization Answer: 2. The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel. 15. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply. Page25 1. Failure to replace body fluids 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 5. Excessive bumetanide administration 6. Lack of follow-up nursing actions Answers: 2, 3, 4, and 6. To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury. 16. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 1. Monitor the client’s ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client’s ability to move the extremities. Page26 5. Inspect the puncture site for swelling, redness, and drainage. 6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours. Answers: 1, 2, 4, and 5. Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider’s prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client’s condition. The nurse checks the puncture site for redness and drainage, and monitors the client’s ability to void and move the extremities. 17. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients? 1. A client complaining of muscle aches, a headache, and malaise 2. A client who twisted her ankle when she fell while rollerblading 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Answers: 4. In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as non urgent, and they are the number 3 priority. Page27 18. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency. Answers: 1 Living wills are required to be in writing and signed by the client. The client’s signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care. 19. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply. 1. “I enjoy exercising but I need to be careful.” 2. “I need to pace my activities throughout the day.” 3. “I need to limit playing football to only the weekends.” 4. “I should gauge my activity level by my energy level.” 5. “I should exercise in the evening to encourage a good sleep pattern.” Answers: 3 and 5. The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity. Page28 20. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler’s side-lying position Answers: 1, 2, 3, and 4. Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide, a rapidacting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful. 1. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply. 1. Scant mucus 2. Early onset cough 3. Marked weight loss Page29 4. Purulent mucus production 5. Mild episodes of dyspnea Answers: 2, 4, and 5. Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea. 2. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client’s ability to function 2. Identifying the client’s potential for self-harm 3. Inquiring about the client’s feelings that may affect coping 4. Inquiring about the client’s perception of the cause of the neighbor’s death Answer: 3. The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client’s feelings. Options 1, 2, and 4 do not directly address the client’s feelings. 3. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing through the sleeve, followed by the client’s arm Page30 Answer: 2. The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change. 4. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client on a ventilator 2. A client in skeletal traction 3. A postoperative client preparing for discharge 4. A client admitted on the previous shift who has a diagnosis of gastroenteritis Answer: 1. The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients described in options 2, 3, and 4 have needs that would be identified as intermediate priorities. 5. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular Answer: 2. The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is Page31 considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority. 6. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client’s bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client’s room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway Answer: 1, 2, 3, and 4. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device. 7. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply. 1. On the left side 2. With the neck flexed 3. Supine on the left side 4. With extreme hip flexion 5. In a semi-Fowler’s position 6. With the head in a midline position Answers: 5 and 6. Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote Page32 venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents. 8. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone. Answer: 3. 9. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? 1. Gloves and a gown 2. Gloves and goggles 3. Gloves, a gown, and goggles 4. Gloves, a gown, and shoe protectors Answer: 3. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary. Page33 10. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Answer: 2 The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis. 11. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely observe? 1. Respirations that cease for several seconds 2. Respirations that are regular but abnormally slow 3. Respirations that are labored and increased in depth and rate 4. Respirations that are abnormally deep, regular, and increased in rate Answer: 4. Kussmaul’s respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate. 12. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. Page34 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 5. Encourage coughing and deep breathing. 6. Educate regarding symptoms of retinal detachment. Answers: 1, 2, 3, 4, and 6. An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse’s assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client. 13. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes Answer: 4. Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with Hyponatremia, a rapid thready pulse is noted. Page35 14. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches Answer: 3. Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4. 15. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply. 1. Call a code blue. 2. Notify the registered nurse. 3. Place the infant in a prone position. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask. Answers: 2, 4, 5, and 6. The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous Page36 return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed. 16. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply. 1. Oliguria 2. Seizures 3. Contractions 4. Proteinuria 3+ 5. Muscle cramps 6. Blood pressure 168/116 mm Hg Answers: 1, 4, and 6. Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences. 17. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply. 1. Bradycardia 2. Fever 3. Sweating Page37 4. Agitation 5. Pallor Answers: 2, 3, and 4. Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur. 18. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. 1. Severely anxious client 2. Pneumonia client 3. Diabetic mellitus client 4. Malnourished client 5. Asthma client 6. Renal failure client Answers: 3, 4, and 6. Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis. 19. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs Page38 3. To place an eye shield on the surgical eye at bedtime 4. That episodes of sudden severe pain in the eye is expected 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort Answers: 1, 3, 5, and 6. After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over. 20. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To place an eye shield on the surgical eye at bedtime 4. That episodes of sudden severe pain in the eye is expected 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort Answers: 1, 3, 5, and 6. After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over Page39 the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over. 1. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply. 1. Cola is acceptable to drink on the day of the test. 2. Tea and coffee are restricted on the day of the test. 3. The test will take between 45 minutes and 2 hours. 4. The hair should be washed the evening before the test. 5. All medications need to be withheld on the day of the test. 6. A nothing-by-mouth (NPO) status is required on the day of the test. Answers: 2, 3, and 4. Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test. 2. The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply. 1. “Increase water intake.” 2. “Increase calcium intake.” 3. “Take pulse rate each day.” 4. “Weigh at the same time each day.” Page40 5. “Palpitations may occur early in therapy.” 6. “Be careful when rising from sitting to standing.” Answers: 3, 4, 5, and 6. Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease. 3. A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply. 1. Tuck pant legs into socks. 2. Wear closed shoes when hiking. 3. Apply insect repellent containing DEET. 4. Cover the ground with a blanket when sitting. 5. Remove attached ticks by grasping with thumb and forefinger. 6. Wear long sleeves and long pants in dark colors when in high-risk areas. Answers: 1, 2, 3, and 4. Measures to prevent tick bites focus on covering the body as completely as possib [Show More]

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