NURSING 1460|ATI Exam prep (Test Bank),Latest Spring 2020,Complete.

EXAM#1 The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in thi ...

EXAM#1 The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client? Deferasirox Deferiprone Deferoxamine Ferrous gluconate Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity? Toxoid Killed vaccine Live attenuated vaccine Specific immune globin Arrange the sequence of steps required to stimulate antibody-mediated immunity in its correct sequence. 1. Exposure of antigen 2. Antigen recognition 3. Sensitization 4. Antibody production 5. Antigen eliminationWhich leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply. Monocyte Memory Cell Helper T cell B-lymphocyte Cytotoxic T cell Which conditions result in humoral immunity? Select all that apply. Tuberculosis Atopic diseases Bacterial infections Anaphylactic shock Contact dermatitis Which type of immunity will clients acquire through immunizations with live or killed vaccines? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? Urticaria A drug reactionAtopic dermatitis Allergic contact dermatitis A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? Histamine Cytokine Neutrophil Macrophage A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? Type I Type II Type III Type IV A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? Angioedema Allergic rhinitis Contact dermatitis Good pasture syndromeA client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? Type I Type II Type III Type IV The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Report to the primary healthcare provider Stop the blood transfusion immediately Recheck identifying tags and numbers on the client Maintain a patent intravenous (IV) line with saline solution The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? Increase in blood pressure Decrease in erythropoietin Increase in serum phosphate levels Decrease in serum sodium concentrationAn elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? The nurse should wait for the court’s order to give blood to the client. The nurse should proceed with the transfusion in order to save the client’s life. The nurse should inform the primary healthcare provider and not give blood to the client. The nurse should explain to the family member that the client needs this transfusion. Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? Obtain the vital signs. Stop the transfusion. Assess the pain further Increase the flow of normal saline. While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? Panic Hemolytic Anaphylactic Pyrogenic During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize ​the following nursing actions 1. Elevate the head of the bed to 45 degrees 2. Apply oxygen via nasal cannula 3. Reduce the flow rate of the transfusion 4. Administer furosemide (Lasix) per provider prescription 5. Document findings in the client recordA prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect? Urticarial reaction Hemolytic reaction Circulatory overload Anaphylactic reaction A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted thru food?" The nurse should respond, "The type of hepatitis associated with food is hepatitis: A B C D Th e nurse is teaching a client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the patient to take to enhance absorption of iron? Cereal Spinach Whole milk Orange Juice A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste productsOn admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias Which blood gas result should the nurse expect a client with diabetic ketoacidosis to exhibit? pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L) A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? Montitoring electrolytes Preventing falls Giving antiemetics Adjusting diuretic therapy A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO2 A decreased pH, elevated PCO2 An elevated pH, decreased PCO2 A decreased pH, decreased PCO2A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? Chronic pain Risk for injury Electrolyte imbalance Inadequate gas exchange Which medication requires the nurse to monitor the client for signs of hyperkalemia? Furosemide Spironolactone Metolazone Hydrochlorothiazide Which hormone synthesis does the nurse state is inhibited by hypokalemia? Aldosterone Norepinehrine Somatostatin Androstenedione Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? Elevation of the ST segment Lowering of the T wave Shortening of the QRS complex Increased deflection of the Q waveA client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. Which statement/intervention is most accurate when administering potassium chloride intravenously to this client with hypokalemia? Rapid infusion of potassium prevents burning at the IV site. Oliguria is an indication for withholding intravenous (IV) potassium Clients with severe deficits should be given IV push potassium. Average IV dosage of potassium should not exceed 60 mEq in one hour. A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? Furosemide (Lasix) Propranolol (Inderal) Digoxin (Lanoxin) Spironolactone (Aldactone) Which assessment finding in a client signifies a mild form of hypocalcemia? Seizures Hand spasms Numbness around the mouth Severe muscle cramps A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up? “I will ask the client to avoid exposure to new infectious agents." "I will ask the client about intake of vitamins and micronutrients." "I will ask the client to avoid involvement in community activities." "I will ask the client if he or she is up to date with recommended vaccines."The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? STAGE 1 STAGE 2 STAGE 3 STAGE 4 The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client’s condition should the nurse report to the primary healthcare provider within 24 hours after observation? Client A Client B Client C Client DA nurse is educating a client with human immunodeficiency virus (HIV) about self-management. Which suggestion by the nurse benefits the client? "Limit your daily fluid intake "Rinse your mouth with normal saline after every meal." "Eat more roughage." "Maintain a 4-to-5-hour gap in between meals." The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? Keeping fresh flowers in the client’s room Encouraging the client to eat fresh fruits and vegetables Keeping a dedicated disposable glove box in the client’s room Changing gauze-containing wound dressings every other day Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? Pneumocystis jiroveci pneumonia Oropharyngeal candidiasis Cryptosporidiosis Toxoplasmosis encephalitis A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? Adhere to standard precautions at all times Avoid handling equipment used in direct client care Discuss procedures that can be performed with a review panelDisinfect all equipment used for non-invasive procedures A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)? CD4 T cell count Western blot test Enzyme-linked immunosorbent assay (ELISA) Polymerase chain reaction test The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? Respiratory alkalosis Normal acid-base balance Poor oxygen perfusion Compensated metabolic acidosis When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? Potassium Sodium Calcium Calcitonin The nurse is preparing to insert an intravenous catheter in a thin, emaciated patient who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. Insert an 18-guage IV catheter Change the intravenous line every 7 days Flush the intravenous line with normal saline Insert the intravenous catheter in the patient’s femurStop the insertion procedure when there is a break in technique A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Intake and output results Client’s report about fluid intake Blood lab results A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication Check the compatibility of the medication and the continuous IV solution Disconnect the continuous IV solution while giving the piggyback medication Flush the client’s access device to ensure patency A client admitted with dehydration is prescribed a bolus infusion of 0.9% sodium chloride(normal saline) 500 ml. IV for 1 hour. An infusion device is available that counts the number of drops per minute delivered. The IV tubing has a drop factor of 10 drops/ml. If the bolus is to infuse on time, the nurse should set the drip rate to ---------- drops per minute. Record your answer, rounding to the nearest whole number. 83 A client presents to emergency department following a motor cycle accident. The client is in hypovolemic shock. The healthcare provider has ordered plasma expansion. What blood product should the nurse anticipate that the client will receive? Packed RBCs Platelets Albumin CryoprecipitateA nurse has received a report on a client being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment findings? Select all that apply. Tachycardia Hypertension Headache Diaphoresis Bounding Peripheral pulses QUIZ#1 What is a nursing priority to prevent complications in clients with respiratory acidosis? Assessing the nail beds Listening to breath sounds Monitoring breathing status Checking muscle contractions The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? PO2 value is 80 mm Hg PCO2 value is 60 mm Hg HCO3 value is 50 mEq/L (50 mmol/L) Serum potassium level is 4 mEq/L A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. HeadacheIrritability Restlessness Hypertension Lightheadedness A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? Question the client about the confusion Change the method of oxygen therapy Percuss and vibrate the client’s chest wall Discontinue or decrease the oxygen flow rate To determine the presence of respiratory alkalosis in a client, what should the nurse evaluate for? A change in the respiratory A tingling sensation in the hands Periodic changes in heart rate A pulse oximetry reading of less than 98% A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO2 A decreased pH, elevated PCO2 An elevated pH, decreased PCO2 A decreased pH, decreased PCO2A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? Skeletal and nervous Circulatory and urinary Respiratory and urinary Muscular and endocrine A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias Which type of immune preparation, made from donated blood, contains antibodies that provide passive immunity?Toxoid Killed Vaccine Live attenuated vaccine Specific immune globin A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? It increases production of short-lived antibodies It accelerates antigen-antibody union at the hepatic sites. The lymphatic system is stimulated to produce antibodies The antigen is neutralized by the antibodies that it supplies. What action describes artificial active immunity? Antibodies are passed from one person to another Antibodies against an antigen are made naturally in the body Antibodies are made after an antigen is injected into the body Antibodies are transferred into the body after being made in another body or animal On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age? Autoimmune response Hypersensitivity response Cell-mediated response Humoral immune response A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)? Shingles PneumoniaMeningococcal Measles, mumps, and rubella (MMR) Haemophilus influenzae type b (Hib) The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action? Administer IV diphenhydramine (Benadryl). Administer nitroprusside as soon as possible Anticipate tracheostomy with laryngeal edema Place the patient recumbent and elevate the legs. Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? Taking more than one medication will put me at risk for developing allergies." "The lower doses of my medications can prevent rejection and minimize the side effects." I will be more prone to malignancies because I will be taking more than one drug." My drug dosages will be lower because the medications enhance each other." Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations? Cells in the transplanted bone marrow are attacking the host tissue An atopic reaction is causing the patient's symptoms The patient is experiencing a type I allergic reaction The patient is experiencing rejection of the bone marrow The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop. Secondary immunodeficiencyPrimary immunodeficiency Acute hypersensitivity reaction Major histoincompatibility When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)? Grapes Oranges Bananas Potatoes Tomatoes A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first? Dyspnea Dilated pupils Itching and edema Wheal-and-flare reaction You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? Sodium falling to 138 mEq/L Potassium rising to 4.1 mEq/L Phosphorus falling to 2.1 mg/dL Magnesium rising to 2.9 mg/d While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? WeaknessParesthesias Facial spasms Muscle tremors You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? The potassium level may be increased if the patient has renal nephropathy. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level. ​The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. The patient may be excreting extra sodium and retaining potassium because of malnutrition. You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? Loop diuretics Bronchodilators Antibiotics Antihypertensives The patient has chronic kidney disease and is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? IV Furosemide (Lasix) Renal dialysis IV potassium chlorideIV normal saline at 250 mL per hour You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. In how many hours should the nurse anticipate hanging the next bag of D5W? __________ hours 4 Y ou are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? Slow the rate to keep vein open until next bag is due at noon Listen to the patient’s lung sounds and assess respiratory status Obtain a new bag of IV solution to maintain patency of the site Notify the physician and complete an incident report OUIZ #2 A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nursemake it a priority to use? Select all that apply. Goggles Surgical Mask Gown Shoes covers N95 mask Gloves The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? Class III Class IIClass IV Class I Which chest examination findings can be observed in a client with pneumonia? Absent sounds on auscultation Prolonged expiration on inspection Hyperresonance on percussion Increased fremitus over affected area on palpation Which client would the nurse consider to have the highest risk of pneumonia? Client 1 Client 2 Client 3Client 4 The nurse suspects pneumonia in a client who underwent placement of an epistaxis catheter due to posterior nasal bleeding. Which activity of the client might have led to this condition? Using drugs such as aspirin Applying excess petroleum jelly to the nares Using nasal saline sprays Blowing the nose vigorously The nurse is using the CURB-65 scale in the assessment of four clients with manifestations of pneumonia. Which client requires immediate admission to the intensive care unit? Client 1 Client 2 Client 3 Client 4A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? Penicillin G Vancomycin Meropenem Ceftriaxone The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Maintaining fluid balance in the client Encouraging the client to perform breathing exercises Providing adequate oxygenation for the client Assisting the client in eating and drinking The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? Inhaling air fully before inserting the mouthpiece Performing 10 breaths per session every hour Taking a long slow, deep breath keeping the mouthpiece in place Recording the volume of the air inspired ​Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? ​Record your answer using a whole number. ___ gtt/minute25 A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? Active range-of-motion exercises at least every four hours Isometric exercises every two hours while awake Gait training in the physical therapy department daily Passive range-of motion exercises at least every eight hours When caring for a client with pneumonia, which nursing intervention is the highest priority​? Employ breathing exercises and controlled coughing increase fluid intake maintain a NPO status Ambulate as much as possible A client with a history of coronary artery disease is admitted with pneumonia. The healthcare provider prescribes atenolol. What should the nurse monitor to determine the therapeutic effect of atenolol? Temperature Respirations Heart rate Pulse oximetry ​A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is ​most​ likely to be present when the nurse assesses the client's right side?Adventitious sounds Wheezing Decreased sounds Crackling A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Increase fluid intake to at least 2L per day Place the client in a high-Fowler position Administer continuous O2 Instruct the client to gargle deep in the throat using warmed normal saline A Patient who is scheduled for open-heart surgery ask why he will be getting chest tubes after surgery. What should the nurse consider before responding in language that the patient will understand? Chest tubes increase tidal volume Chest tubes facilitate drainage of air and fluid Chest tubes regulate pressure on the pericardium and chest wall Chest tubes maintain positive intrapleural pressure A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? Clamp the chest tubes when suctioning the patientPalpate the area around the tubes for crepitus Change the clients dressing daily using aseptic technique Empty the drainage chamber at the end of the shift A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. While planning care for a stationary chest tube drainage system, which purpose of the first chamber will the nurse consider? Sustain a continuance of the water seal Ensure adequate suction Collect drainage Maintain negative pressure During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What ​initial​ action should the nurse take? Turn the client to the unaffected side Check the tube to ensure that it is not kinked Take the client’s vital signs Inform the healthcare provider A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Permit the development of positive pressure between the layers of the pleuraRemove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Provide access for the installation of medication into the pleural space ​Nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop giving the medication Elevate the head of the client’s bed Measure the other vital signs Report to the primary healthcare provider A client has an IV of D​ 5​W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? ​Record your answer using a whole number. ___mL/hr 35 A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? Discuss with spouse the risk for morphine addiction Add a placebo to the morphine to appease the spouse Assess the client’s pain before increasing the dose of morphine Check the client’s heart rate before increasing the morphine to the next level​POP QUIZ #2 A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? Cleanse the site with the new product first and then follow the agency’s protocol Use the new product sample when changing the dressing Follow the agency’s policy unless it is contraindicated by a primary healthcare provider’s prescription Cleanse the site with alcohol first and the with povidone-iodine A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed? There is less chance of this infusion infiltrating It is more convenient so clients can use their hands It prevents the development of infection The large amount of blood helps dilute the unconcentrated solutionA client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted. What is the primary reason total parenteral nutrition is infused through a central line rather than a peripheral line? Apply oxygen Raise the head of the bed Call the primary healthcare provider Assess breath sounds A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do ​first​? Determine which days to self-administer the PPN solution Arranging for professional help to monitor the alternative solution Learning how to change the percutaneous catheter Scheduling administration of the PPN solution around mealtimes A client will be discharged with a peripherally inserted central venous catheter (PICC) for administration of peripheral parenteral nutrition (PPN). What would be appropriate for the nurse to include in the client's discharge teaching? Notify the healthcare provider Inspect the catheter Clamp the remaining device Assess the respiratory status The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in bedclothes and came out. What should the nurse do ​first​? Apply warm compress to the affected extremity Check the IV access for blood return Slow the IV infusion until the burning sensation is goneRequest an oral supplement from the primary healthcare provider A client, receiving a potassium infusion via a peripheral intravenous (IV) site, reports a burning sensation above the IV site. What should the nurse do ​first? Healthcare provider UAP LPN RN A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a ​priority​ for the nurse to assess which of the following? ​Select all that apply. Deep tendon reflexes Urinary output ABG results Last bowel movement Patency of the IV access Last serum potassium level ​A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a ​priority​ for the nurse to assess which of the following? ​Select all that apply. Administering 100% oxygen manually to the client Administering IV fluids to the client Reporting to the primary healthcare providerStopping the suctioning procedure immediately ​A nurse is providing tracheostomy care. Which action is ​priority​? Monitor body temperature after the procedure is completed Maintain sterile technique during the procedure Clean the inner cannula with sterile water when it is removed Place the client in the semi-Fowler position Surgical incision in the chest to gain access to the internal organs is ​THORACOTOMY VATS=​Video assisted thoracoscopic surgery The valve used to evacuate air from the pleural space is called ​Flutter valve of Heimlich valve Give the patient pain medication 30-60 minutes before chest tube removal TRUE QUIZ#3 A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? Barium enema Colonoscopy Gastroscopy CT scan An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet should the nurse encourage the client to follow? High fiber Low fat Low carb High proteinA client who had surgery for a ruptured appendix develops peritonitis. Which clinical findings related to peritonitis should the nurse expect the client to exhibit? ​Select all that apply​. Abdominal muscle rigidity Hyperactivity Urinary retention Extreme hunger Fever A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client? Dorsal recumbent Semi-Fowler Sims Trendelenburg A colectomy is scheduled for a 38-year-old woman with ulcerative colitis. The nurse should plan to include what prescribed measure in the preoperative preparation of this patient? Administration of a cleansing enema A high fiber diet the day before the surgery Administration of IV antibiotics for bowel preparation Instruction on irrigating a colostomy A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 8:00AM, 12:00PM and 4:00PM 7:00AM, 10:00AM, and 1:00PM 9:00AM and 3:00PM9:00AM, 12:00PM, and 3:00PM Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of Nasogastric suctioning Impaired peristalsis Irritation of the bowel Inflammation of the incision site The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A decrease in appetite by 50% over 24 HRs Muscle tremors and other signs of hypomagnesemia Abdominal pain and bloating No bowel movement for 3 days The nurse asks a 68-year-old patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the ​most​ appropriate action by the nurse? Delay the patient’s signature on the consent and notify the physician about the conversation with the patient Ask the family members whether they have discussed the surgical procedure with the physician. Explain the planned surgical procedure as well as possible and have the patient sign the consent form Have the patient sign the consent form and state the physician will visit to explain the procedure before surgery The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is ​most ​appropriate?The tube will push past the area that is blocked and thus help to stop the vomiting The tube will help to drain the stomach and prevent further vomiting The tube is just a standard procedure before many types of surgery to the abdomen The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess ​first​? Fecal impaction Antidiarrheal agent use Dietary fiber intake Perineal hygiene What information would have the ​highest priority​ to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? Which medications will be used during surgery The location and care of drains after surgery How to care for the wound How to deep breathe and cough The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? Increases peristalsis by stimulating nerves in the colon wall Increases fluid by retention in the intestinal tract Increases bulk in the stool Lubricates the intestinal tract to soften feces The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet Eat several small meals per day to maintain bowel motility Reduce intake of medications causing constipation Sit upright during meals to increase bowel motility by gravityA patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the interchange. Available is a syrup that contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer. _______________ mL 10 Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority​ action by the nurse? Notify the physician Reposition the tube and check for placement Auscultate for bowel sounds Remove the tube and replace it with a new one When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? Dried beans, All bran (100%) cereal, and raspberries Oranges, baked potatoes, and raw carrots White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? The patient must be able to access the site The ostomy will need to be irrigated so the area should not be tender Outside the rectus muscle area is the best site It is easier to seal the drainage bag to a protruding area When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? Dried fruit and popcorn must be chewed very well The drainage from the stoma can damage my skinI will be able to wear the pouch until it leaks I will be able to regulate when I have stools The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? High-pitched and hyperactive above the area of obstruction Low-pitched and rumbling above the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hypoactive below the area of obstruction What should the nurse instruct the patient to do to ​best​ enhance the effectiveness of a daily dose of docusate sodium (Colace)? Ensure dietary intake of 10g of fiber each day Take a dose of mineral oil at the same time Add extra salt to food on at least one meal tray Take each dose with a full glass of water or other liquid A client with a diagnosis of gastric cancer has a gastric resection with a vagotomy. Which clinical response should alert the nurse that the client is experiencing dumping syndrome? Constipation Clay-colored stools Reactive hypoglycemia Sensations of hunger A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? Low-protein, high-carb diet Fluid intake below 500mL Small, frequent feeding schedule Low-residue, bland dietThe nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which statement by the client indicates a good understanding of preventing dumping syndrome after meals? ​Select all that apply​. I will not drink fluids when I eat meals I will eat a bland diet I will eat a low-protein, high carb diet I will avoid artificially-sweetened foods I will eat small, frequent meals instead of three large meals a day After a subtotal gastrectomy a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. What does the nurse determine is the cause of the latter effect? A distention of the duodenum from an excessive amount of chyme A second more extensive rise in glucose An overproduction of insulin that occurs in response to the rise in blood glucose An overwhelmed insulin-adjusting mechanism The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? ​Select all that apply. Eat small frequent meals Select foods that are low in fiber Drink fluids with meals Lie down for one hour after eating Chew food five times before swallowing A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes what physiologic response? Constipation Vomiting FeverPalpitations CRANIAL NERVES QUIZ Glossopharyngeal Nerve: innervates the pharynx Optic Nerve: vision Facial Nerve: control of facial muscles Vestibulocochlear: equilibrium and hearing Hypoglossal: innervates the tongue muscles Vagus: controls visceral and cardiac muscles; cranial nerve that innervates smooth muscle and glands of the heart, lungs, larynx, trachea, and most abdominal organs Trigeminal: controls muscles of mastication Cerebellum: controls posture, balance, and the coordination of body movements Medulla oblongata: the respiratory, cardiac, and vasomotor control centers are located here After a major head trauma, the patient's respiratory and cardiac functions are affected. Which area of the brain is damaged? Temporal lobe of the cerebrum Brainstem Cerebellum Spinal Nerves What is the purpose of the blood-brain barrier? To protect the brain by cushioning To inhibit damage from external trauma To keep harmful agents away from brain tissue To provide the blood supply to brain tissueWhen assessing a patient with a traumatic brain injury, you notice uncoordinated movement of the extremities. How would you document this? Ataxia How do you assess the accessory nerve? Assess the gag reflex by stoking the posterior pharynx Ask the patient to shrug their shoulders against resistance Ask the patient to push the tongue to either side against resistance Have the client say “ah” while visualizing elevation of the soft palate When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this finding? Athetosis Hypotonia Hemiparesis Pronator drift DIABETES QUIZ A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician's prescriptions? Endotracheal intubation 100 units of NPH insulin IV infusion of normal saline IV infusion of sodium bicarbonate "A client is taking Humulin NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: 2-4 HRS after administration 4-12 HRS after administration16-18 HRS after administration 18-24 HRS after administration A client with diabetes mellitus has a blood glucose of 644 mg/dl. The nurse interprets that this client is most at risk of developing which type of acid base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis A client with type I diabetes is placed on an insulin pump. The most appropriate short-term goal when teaching this client to control the diabetes is: Adhere to the medical regimen Remain normoglycemic for 3 weeks Demonstrate the correct use of the administration equipment List 3 self-care activities that are necessary to control the diabetes "A diabetic patient has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. Following assessment of the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of Polyuria Severe dehydration Rapid, deep respirations Decreased serum potassium ​An 18-year-old female client, 5'4'' tall, weighing 113 kg, comes to the clinic for a non-healing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client is developing? Type 1 diabetes Type 2 diabetes Gestational diabetes Acanthosis nigricansAn external insulin pump is prescribed for a client with DM. The client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: Gives small continuous dose of regular insulin subcutaneously and the client can self-administer a bolus with an additional dosage from the pump before each meal Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? BP 126/80 A1C 9% FBG 130 mg/dL LDL cholesterol 100 mg/dL One of the benefits of glargine (Lantus) insulin is its ability to: Release insulin during the day to help control the basal glucose Release insulin evenly throughout the day to control basal glucose levels Simplify the dosing and better control blood glucose levels during the day Cause hypoglycemia with other manifestation of other adverse reactions The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with Type 1 diabetes at 1600. Which action should the nurse implement? Ensure the client eats the bedtime snack Determine how much food the client ate at lunch Perform a glucometer reading at 0700 Offer the client protein after administering insulinYour patient’s blood glucose level is 215 mg/dL. The patient is about to eat lunch. Per sliding scale, you administer 4 units of Insulin Lispro (Humalog) subcutaneously at 1130. As the nurse, you know the patient is most at risk for hypoglycemia at what time? 1145 1230 1430 1630 RAPID-ACTING​: onset 15mins, peak 1 hour, duration 3 hours SHORT-ACTING​: onset 30mins, peak 2 hours, duration 4 hours INTERMEDIATE-ACTING​: onset 2 hours, peak 4 hours, duration 16 hours LONG-ACTING​: onset 1 hour, no peak, duration 24 hours Regular ®:short-acting Humalog :rapid-acting Novalog: rapid-acting NPH (N): Intermediate Lantus: long-actingQUIZ #4 The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client’s condition? Potassium 8 mEq/L Phosphorus 7 mg/dL Bicarbonate 15 mEq/L Hemoglobin 10 g/dL A client is diagnosed as having kidney failure. During the oliguric phase, what should the nurse assess for in this client? Hyperphosphatemia Hypernatremia Hypocalcemia Hypothermia A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? Hypertension Acidosis Ascites Hyperkalemia A client is experiencing kidney failure. Which is the ​most​ serious complication for which the nurse must monitor a client with kidney failure? Anemia Uremic frost Weight loss HyperkalemiaA nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? ​Select all that apply. Hypotension Muscle twitching Polyuria Respiratory acidosis Lethargy A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? Impaired GFR, causing retention of sodium and metabolic waste products Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy? It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion It decreases the need for immobility because it clears toxins in short and intermittent periods It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? Protein Fluid SodiumPotassium A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? Increases urinary output Prevent respiratory acidosis Correct Hyperkalemia Increases serum calcium levels A nurse is caring for a client with acute kidney injury. Which findings should the nurse anticipate when reviewing the laboratory report of the client’s blood level of calcium, potassium, and creatinine? Select all that apply. Creatinine 1.1 mg/dL Calcium 7.6 mg/dL Creatinine 3.2 mg/dL Potassium 3.5 mEq/L Calcium 10.5 mg/dL Potassium 6.0 mEq/L ​A client with acute kidney injury states, "Why am I twitching and my fingers and toes tingling?" Which process should the nurse consider when formulating a response to this client? Sodium chloride depletion Calcium depletion Acidosis Potassium depletion A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take ​first? Obtain an ECG strip and obtain an antiarrhythmic medication Take vital signs and notify the HCP Call RRT Call the lab to repeat the testA nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client’s questions? Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? It will prevent the development of pneumonia and a high fever It equals the expected urinary output for the next 24 hours It will compensate for both the insensible and expected output over the next 24 hours It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias Which type of cytokine is used to treat anemia related to chronic kidney disease? Interleukin-2 Erythropoietin Interleukin-11 a-Interferon A client with the diagnosis of chronic kidney disease develops hypocalcemia. Which clinical manifestations should the nurse expect the client with hypocalcemia to exhibit? Select all that apply. Osteomalacia Fractures Lethargy Eye calcium deposits AcidosisA client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client’s spouse asks the nurse about the anticipated plan of care. Which is an appropriate nursing response? The staff will provide total care, because the infection causes severe fatigue Mood elevators will be prescribed to improve depressions and irritability Vitamin B12 will be prescribed for the anemia and the stools will be dark The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products A client is admitted to the hospital with a diagnosis of severe chronic kidney disease. Which assessment findings should the nurse expect the client to exhibit? Select all that apply. Paresthesias Widening pulse pressure HTN Polyuria Metabolic alkalosisEXAM #2 When a nurse brings a dinner tray to a 44 year old patient hospitalized with pneumonia, the patient says, "I'm too sick to feed myself." What is the best response by the nurse? You can eat later when you feel better." You're really not that sick, and I'm sure you can feed yourself. Try to eat as much as you can. Wait a few minutes, and I will be back to help you. An 50-year-old patient with viral pneumonia is admitted to the telemetry unit. The admitting nurse reviews the instructions from the healthcare provider. Which prescription should the nurse question? Start IV fluids D5% 0.45% NS at 80 mL/hr Aspirin 325 mg every 4 hours prn for fever higher than 101.4° F (38.6° C) physiotherapy twice a day Encourage oral fluids A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Promote bed rest with raised head of bed 2. Provide oxygen via nasal cannula 3. Obtain blood specimens for C&S 4. Administer prescribed antibiotic A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Obtain data about the client’s history and physical status 2. Insert an IV catheter to establish venous access 3. Collect sputum sample for culture and sensitivity 4. Administer prescribed antibiotic IVPB 5. Check peak and trough levels of the antibioticA client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client? The weaning process increases the amount of respiratory secretions. Humidified oxygen is saturated with fluid. The tracheostomy tube interferes with effective coughing. The inner cannula of the tracheostomy tube irritates the mucosa. A platelet transfusion is to be administered for a patient with acute lymphocytic leukemia. What will the nurse do first? Check the vital signs every 2 hours during the transfusion Administer the platelets rapidly through the intravenous (IV) line Flush the IV line with a dextrose solution Set the IV pump to run for 8 hours For a patient with the diagnosis of acute lymphocytic leukemia (ALL). A blood transfusion is ordered, and an intravenous line is started. What will the nurse do in regard to administering the transfusion? Take the vital signs 3 hours after the transfusion. Have the blood warm at room temperature for 1 hour before administration. Infuse the blood over no more than 4 hours. Check the vital signs 15 minutes after starting the transfusion.A Patient who has been prescribed prednisone and vincristine for leukemia tells the nurse that he is very constipated. What should the nurse cite as the probable cause of the constipation? The leukemic mass is obstructing the bowel. The spleen is compressing the bowel. It is a toxic effect from the prednisone. It is a side effect of the vincristine. A nurse is caring for a Patient with acute lymphoid leukemia. While examining the laboratory results, the nurse notes that the patient is neutropenic. What does the nurse recognize as the cause of the neutropenia? Overwhelming infection Increased immature cell growth Internal bleeding Decreased intake of iron-rich nutrients When providing care for a patient with leukemia, a nurse notes blood on the pillowcase and several bloody tissues. What blood component value on the patient's laboratory results should the nurse verify? Erythrocytes Platelets Neutrophils Lymphoblasts A patient who is recently diagnosed leukemia ask the nurse why he was told that he has too many white blood cells. How should the nurse respond? The bone marrow is not controlling your white blood cell production as it should You seem to be focusing on your white blood cells The doctor is the best one to answer that question for you You apparently don't understand what occurs in this disease. A nurse is performing an assessment on a patient who has been admitted to the medical unit with the diagnosis of acute lymphocytic leukemia (ALL). What early clinical findings does the nurse expect to identify? Nosebleeds and papilledemaEnlargement of the axillary and groin lymph nodes Abdominal pain and reddened complexion Fatigue and ecchymotic areas A patient who has acute lymphoblastic leukemia is scheduled to receive cranial radiation. What should the nurse explain to the patient and family about radiation? It reduces the risk for systemic infection. It prevents central nervous system involvement. It limits metastasis to the lymphatic system. It avoids the need for chemotherapy. A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? Conjunctiva Mucous membrane Sclera LipsA nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease? Client 1 Client 2 Client 3 Client 4 A nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension? Client AClient B Client C Client D A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? Junctional tachycardia Bradycardia HTN Headaches A nurse is discussing dietary guidelines to help reduce a client’s risk for heart disease. What should the nurse teach the client? Limit the amount of unsaturated fat. Eat small, frequent meals Increase complex carbohydrates. Decrease the amount of proteins. A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding? 1.Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." 2. Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta 3. "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." 4. Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava."A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. Olive oil Enriched whole milk Chicken broth Liver and other glandular organ meats Red meats such as beef Vegetables and whole grains A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply Diabetes insipidus African-American ancestry Obesity Increased high-density lipoprotein (HDL) HTN What are the clinical manifestations of myocardial infarction in women? Select all that apply. Tightness of the chest Indigestion Sleep disturbances Unusual fatigue AnoxiaThe nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction? Client A Client B Client C Client D A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? Sodium bicarbonate Atropine Amiodarone EpinephrineA client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication? HTN Nausea Bradycardia Syncope Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective? I should take the medicine three times a day." "I will be sure to take my pulse after I have exercised." "I should take one tablet before attempting to climb two flights of stairs." "It will be important to avoid activities that are too strenuous." A client is admitted for chest pain and a myocardial infarction. The nurse caring for the client is preparing to apply nitroglycerin ointment. Before applying the ointment, what action will the nurse take? Assess the client's pulse rate. Shave the client’s chest in the area for application. Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount. Prepare the site with an alcohol swab. A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of what drug? Digoxin Furosemide Captopril Morphine sulfateA client who is hospitalized after a myocardial infarction asks the nurse why morphine was prescribed. What will the nurse include in the reply? Helps prevent development of atrial fibrillation Relieves pain and reduces myocardial oxygen demand Dilates coronary blood vessels to increase oxygen supply Decreases anxiety and promotes sleep A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. What intervention will be most effective in relieving the client's pain? Oxygen per nasal cannula Morphine sulfate 2 mg IV Nitroglycerin sublingually Lidocaine hydrochloride 50 mg IV bolus A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. What does the nurse identify as the purpose of the nitroglycerin patch? Decreased cardiac preload reduces cardiac workload Peripheral venous and arterial constriction increases peripheral resistance Increased cardiac output increases oxygen demand Decreased HR lowers cardiac output A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the preprocedure teaching? The procedure will take approximately 15 minutes to complete. Mild sedation is maintained during the procedure. Ambulation is encouraged shortly after the procedure It will take approximately 24 hours to determine whether blockage is present.A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? "This test will detect your heart sounds." The ECG will tell us how much stress your heart can tolerate." "This test will reflect any heart damage." "This procedure helps us change your heart’s rhythm." The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Warm, flushed skin Decreased urinary output Rapid pulse Increased BP Deep respirations A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. Restlessness Bradypnea Decreased urinary output Tachypnea Warm, moist skin A woman comes to the emergency department reporting signs and symptoms that are determined by the primary healthcare provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply. Severe fatigue Pain radiating down the left arm Choking sensation Sense of uneaseChest pain relieved by rest A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? Mild, radiating toward the abdomen Burning and of short duration Severe, intense Squeezing, relieved by nit A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client’s ventricular contractions? Monitoring urinary output hourly Assessing breath sounds frequently Observing anxiety levels Evaluating cardiac enzyme results A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client’s temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what? Respiratory infection Venous thrombosis Tissue necrosis Pulmonary infarction A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? Are you feeling anxious?" "Do you have any palpitations?" "Do you have chest pain?" "Are you feeling short of breath?"A client presents to the emergency department with symptoms of Congestive Heart Failure(CHF) after having an myocardial infarction (MI). Which results will the nurse expect to find upon assessment? Elevated brain natriuretic peptide (BNP) level Elevated serum troponin I Decreased creatine kinase-MB (CK-MB) Decreased breath sounds A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? Heart muscle ischemia Irritation of nerve endings in the cardiac plexus Arterial spasm Blocking of the coronary veins A client who has a history of several myocardial infarctions is admitted to the hospital for an unrelated medical condition. Because of the client's history, the nurse is concerned about the possibility of the client experiencing right ventricular failure. Which early indication of right ventricular failure should the nurse monitor for in this client? Bradycardia Peripheral edema Chest pain Bradypnea Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give? "There is going to be an additional delay. The client who just arrived had a heart attack, and that client needs care first." ​ "I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen." "We will be busy for a while. Unfortunately, we have to take care of this other clientfirst." "I recognize that you have been waiting for quite a while, but it now looks like you will have to wait even longer." A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow Increase left ventricular filling and improve cardiac output A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Decreased catecholamine secretion Increased parasympathetic nervous system stimulation Myocardial hypoxia Metabolic alkalosis A nurse is developing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. Which statement from the client indicates the nurse needs to intervene? I will restrict my physical activity." I will take one baby aspirin every day." I will try to lose the extra weight I'm carrying around." I will continue my smoking cessation program." A client who is recovering from an acute myocardial infarction reports not being happy about the lack of salt with meals. Which information should the nurse share with the client about the purpose of salt restriction? This prevents further fluid accumulation, which increases the workload of the heart.This reduces the circulating blood volume by a diuretic effect. This reduces the amount of edema, which interferes with heart action. This prevents an increase in blood pressure from tissue edema. A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client’s condition? Perform daily weights Assess for dependent edema Monitor intake and output Auscultate breath sounds A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. Chest pain Frothy sputum Bradypnea Cyanosis Crackles The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? "Would you like me to ask your primary healthcare provider to change the prescription?" "Bed rest plays a role in most therapy." "​Rest helps your body direct energy toward healing." "Why do you want to be out of bed?"What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? Elevate the client’s lower extremities. Place the client in the orthopneic position. Prepare for modified postural drainage. Encourage frequent coughing. A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? Check the client’s blood glucose levels. Instruct the client to remove his or her dentures. Obtain informed consent from the client. Assess if the client is allergic to shellfish. Which diagnostic test would the nurse consider to be the gold standard for diagnosis of pulmonary embolism? Pulmonary angiography Computed tomography pulmonary angiography (CT-PA) Helical computed tomography (CT) Ventilation-perfusion (V/Q) scans A nurse teaches a client about wearing thigh-high anti embolism elastic stockings. What would be appropriate to include in the instructions? "You do not need to wear them while you are awake, but it is important to wear them at night." "You will need to apply them in the morning before you lower your legs from the bed to the floor." "If they bother you, you can roll them down to your knees while you are resting or sitting down." "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? Chlorpromazine Ferrous sulfate Atenolol Acetylsalicylic acid A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 76-year-old who has a history of thrombocytopenia A 68-year-old who had emergency dental surgery A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? Pink Yellow Clear Green The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. Sudden chest pain Flushing of the face Abrupt onset of shortness of breath Elevation of temperature Pain rating increase from 2 to 8 in the hipThe nurse provides care for a Chinese patient who is experiencing leg pain. The patient states, "I don’t want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? Give morphine (Avinza) to the patient with hot teaphine (Avinza) to the patient with hot tea Give ibuprofen (Advil) to the patient with cold water Give ibuprofen (Advil) to the patient with hot tea Postpone medication administration to the patient A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? Turn the machine on several times a day for 10 to 20 minutes Apply the color-coded electrodes on the client where they are most comfortable. Maintain the settings programmed by the healthcare provider. Adjust the dial on the unit until the client states the pain is relieved. The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply. Pruritus Constipation Nausea and vomiting Respiratory rate SedationThe nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment? Client A Client B Client C Client D The registered nurse teaches the student nurse regarding the priority of care provided to clients with chest pain. Which activity performed by the student nurse indicates effective learning? Auscultating heart and breath sounds Placing the client in upright position Assessing airway, breathing, and circulation (ABC) Administering oxygen via nasal cannula A nurse is caring for a client with pain due to muscle spasm. Which nursing action is beneficial for the client? Providing heat compresses at the site Encouraging the client to perform isometric exercises Providing a massage to the affected area Encouraging the client to do active-passive range-of-motion (ROM) exercisesEXAM #3 The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase. The nurse evaluates that teaching is understood when the client identifies which time for medication scheduling? On arising each morning At bedtime One hour before meals With meals A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access? It permits free use of the hands. The chance of the infusion infiltrating is decreased. The amount of blood in a major vein helps to dilute the solution. Infection is uncommon. A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas? Maintain the gastric pH at a level less than 3.5. Ensure that the nasogastric tube remains in the fundus of the stomach. Administer the histamine H2-receptor antagonist as prescribed Encourage the resumption of activities of daily living. The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? "Meals should be restricted in protein because of your compromised liver function." "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism." "There are no dietary restrictions because the tumor has been removed." "Your diet should be low in calories to prevent taxing your diseased pancreas."After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and the endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of what substances? Fats and carbohydrates Alcohol and caffeine Fluids and electrolytes Vitamins and minerals A nurse is caring for a client who had a pancreaticoduodenectomy for cancer of the pancreas. The nurse provides education about hypoinsulinism, a long-term complication related to this type of surgery. The nurse evaluates that the teaching is understood when the client states that he will seek medical supervision if he experiences which symptom? Oliguria Weight gain Anorexia Increased thirst A client with an inoperable cancer of the head of the pancreas involving the common bile duct has a T-tube inserted. During the first 48 hours after insertion of the tube, what should the nurse do? Ensure that the T-tube is connected to low intermittent suction Use normal saline to irrigate the T-tube every two hours Avoid positioning the client on the right side where the T-tube is located Maintain T-tube patency via gravity drain A client newly diagnosed with cancer of the pancreas is scheduled for surgery. The client says to the nurse, "Wouldn't I be better off with some other treatment instead of surgery?" What response by the nurse is the best? "Surgery is the recommended approach. Why don't you discuss this further with the healthcare provider?""It's a good idea to explore other acceptable treatments for your cancer. There is information available for you." "Maybe you will be more confident with a second opinion. I think you need a referral to another healthcare provider." "With your disease your prognosis will improve if you follow the suggestion to have the recommended surgery." A client is admitted to the hospital with jaundice. After numerous diagnostic tests, the healthcare provider makes the diagnosis of cancer of the pancreas. What does the nurse conclude is the most likely cause of the client’s jaundice? Obstruction of the common bile duct by the pancreatic neoplasm Excessive serum bilirubin caused by red blood cell destruction Necrosis of the parenchyma caused by the neoplasm Impaired liver function, resulting in incomplete bilirubin metabolism A client was diagnosed with cancer of the head of the pancreas two months ago. The client is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the client's assessment, the nurse expects the client's stool to be what color? Clay-colored Green Red-tinged Brown A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides what benefit? Is the safest method for meeting the client's nutritional requirements Will meet the client's nutritional needs without causing the discomfort precipitated by eating Is the easiest method for administering needed nutrition Will satisfy the client's hunger without the discomfort associated with eatingA client is admitted to the hospital for medical management of acute pancreatitis. Which nursing action is most likely to reduce the pancreatic and gastric secretions of a client with pancreatitis? Obtaining a prescription for morphine Encouraging clear liquids Assisting the client into a semi-Fowler position Administering prescribed anticholinergic medication A client who is obese and has a history of alcohol abuse is admitted to the hospital with the diagnosis of acute pancreatitis. Which is the initial priority expected client outcome in response to therapy at this time? Report decreased pain Insert nasogastric (NG) tube quickly Join Alcoholics Anonymous Lose four pounds (1.8 kilograms) a week A client with an obstruction of the pancreatic ducts has been diagnosed with acute pancreatitis. The client's physical condition continues to deteriorate despite supportive care, and a subtotal pancreatectomy is performed. The nurse should monitor the client for what postoperative complication? Respiratory distress Paralytic ileus Cholecystitis Constipation A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? Amylase level Erythrocyte sedimentation rate Red blood cell count Platelet countA client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, what would the nurse expect to observe? Steatorrhea Hard, dry stool Melena Ribbon-shaped stool The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. Daily abdominal girth measurements Daily weights Low sodium diet Encourage increased by mouth fluid intake High protein diet A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites? Palpate the lower extremities over the tibia and observe for edema Percuss the client’s abdomen and listen for dull sounds. Listen for decreased or absent bowel sounds while auscultating the abdomen. Observe the client for signs of respiratory distress. A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. For which condition is it most important for the nurse to assess this client? Nausea Hourly urinary output Blood in the stool Food intolerancesWhat will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver? Monitor the client's vital signs Determine the client's urine albumin level each shift. Obtain the client's weight at least once every day. Measure the client's urine output every half hour. The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond? "This medication helps you lower the high ammonia level caused by your liver disease." "This medication helps you relax and not feel anxious." This medication helps you keep your abdomen from being so distended." "This medication helps you to stop drinking so much alcohol." A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? Bruising Tachycardia Hyperkalemia Hypoglycemia Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication? Reduces the blood ammonia level Prevents an infection Limits abdominal distention Minimizes intestinal edema A client with a history of cirrhosis of the liver develops heart failure. When ventricular bigeminy develops, the provider orders lidocaine. What alterations in lidocaine dosages does the nurse anticipate?Lower because the drug is metabolized at a diminished rate Higher to compensate for the impaired liver function Equal to that needed for other clients to provide a loading dose for the myocardium Reduced because other organs will compensate for the sluggish liver A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which client history item? Pain that increases after meals Joining Alcoholics Anonymous Black, tarry stools Frequent nausea A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse’s best response? "They help the common bile duct contract stronger." "They aid absorption of fat-soluble vitamins." "They promote bilirubin secretion in the urine." "They stimulate prothrombin production." The nurse is assessing a client with severe cirrhosis and discovers fetor hepaticus. What did the nurse assess? Stool Breath Urine Hands A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. Musty, sweet breath odorIncreased cholesterol Mental confusion Brown-colored stools Flapping hand tremors A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? Increased pressure in the portal vein Increased production of serum albumin Increased secretion of bile salts Increased interstitial osmotic pressure A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply. Avoiding aspirin and aspirin-containing products Avoiding acetaminophen and products containing acetaminophen Adhering to a low-carbohydrate diet Avoiding coughing, sneezing, and straining to have a bowel movement Limiting alcohol consumption to two drinks weekly The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? Baked lasagna with sausage, salad, and milkshake Hamburger, french fries, and cola Penne pasta, spinach, banana, and decaffeinated iced tea Ham sandwich with cheese, whole milk, and potato chips A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? Moderate proteinHigh protein Strict protein restriction No protein A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? Monitor respiratory status. Institute fall prevention/safety measures. Test stool specimens for blood. Measure abdominal girth daily. The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? Observe the client for increasing confusion. Weigh the client daily. Restrict the client's oral fluid intake. Measure the client's urine specific gravity. A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? Ammonia level Alanine aminotransferase (ALT) level White blood cell count Culture and sensitivity A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority? Implement fall precautions/prevention measures Administer the prescribed sedative Provide oxygen via a nasal cannula Notify the primary healthcare provider immediatelyA client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? Check the pulse several times a day. Drink a glass of milk when taking aspirin. Report signs of bleeding no matter how slight Avoid foods high in phytonadione. A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any risks after the procedure. Which response by the nurse is the best? "The major risk is bleeding post procedure." "The major risk is infection at the biopsy site." "There are relatively no risks associated with this procedure." "The major risk is liver failure postprocedure." A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? Reduction of colloidal osmotic pressure in the blood Hemorrhage with subsequent anemia Malnutrition of cells, especially hepatic cells Diminished resistance to bacterial insult A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply. Hirsutism Ecchymoses MelanosisVitiligo Telangiectasis A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? Have the client turn to the lateral position. Tell the client not to eat for four hours. Instruct the client to void. Give the client an analgesic. A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. What is the primary cause of the client’s ascites? A decrease in iron to maintain adequate hemoglobin synthesis A decrease in plasma protein to maintain adequate capillary-tissue circulation A decrease in vitamins to maintain cell coenzyme functions A decrease in sodium to maintain its concentration in tissue fluid A nurse is developing a discharge plan for a client hospitalized with severe cirrhosis of the liver. What should be included in this plan? The use of a sedative for relaxation The need to increase fluids The importance of reporting personality changes to the primary healthcare provider The need for a high-protein diet A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number. ___ mL 240 A healthcare provider orders heparin 6000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. How many milliliters of heparinshould the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL 0.6 A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device? Record your answer using a whole number. ___ mL/hr 20 The registered nurse determines that the new graduate understands the type(s) of hepatitis that generally develop into a chronic hepatitis infection if the graduate identifies which disease(s)? Select all that apply. Hepatitis A Hepatitis E Hepatitis B Hepatitis D Hepatitis C The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? "I will eat foods high in carbohydrates, moderate in fats, and moderate in proteins." "I will avoid alcohol." "I will eat small frequent meals." "I will take acetaminophen for pain rather than aspirin." A client who experiences anorexia and fatigue develops jaundice. A diagnosis of hepatitis A is made. The client's spouse and adult children who still live at home ask whether they should receive gamma globulin. Which is the most appropriate response by the nurse?"Your family member's type of hepatitis is no longer communicable, and gamma globulin is not required." "Gamma globulin provides passive immunity for hepatitis B, not hepatitis A." "Gamma globulin is unnecessary as long as you follow droplet precautions." "You should call your primary health care provider immediately about getting gamma globulin." A client is diagnosed with hepatitis A. The nurse takes the client’s history. Which employment history is most likely linked to the development of hepatitis A? Works at an occupational arsenic compound business Works as a dishwasher at a local restaurant Works at a plumbing business Works in a hemodialysis unit at a hospital A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse? "You cannot return to work for six months because the virus will still be in your stools, and you still are communicable." "Unfortunately, few people fully recover from hepatitis in less than six months." "As soon as you're feeling less tired, you may go back to work." "Gradually increase your activities because relapses may occur in those who return to full activity too soon." A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take? Wear a gown when entering the client's room. Wear a protective mask when entering the client's room. Use gloves when removing the client's bedpan. Use caution when bringing in the client's food.A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? Inability of the liver to remove normal amounts of bilirubin from the blood Stimulation of the liver to produce an excess quantity of bile pigments Increased destruction of red blood cells during the acute phase of the disease Decreased prothrombin levels, leading to multiple sites of intradermal bleeding The nurse would question the use of which cathartic agent in a patient with renal insufficiency? Magnesium hydroxide (Milk of Magnesia) Bisacodyl (Dulcolax) Lubiprostone (Amitiza) Cascara sagrada (Senekot) Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of irritation of the bowel. impaired peristalsis. inflammation of the incision site. nasogastric suctioning. The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Sit upright during meals to increase bowel motility by gravity. Eat several small meals per day to maintain bowel motility. Reduce intake of medications causing constipation. Maintain a high intake of fluid and fiber in the diet.Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? Cramping abdominal pain Restricted to rectum Bloody, diarrhea stools Lesions penetrate intestine. Strictures are common. The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? Control abdominal pain Avoid dietary cholesterol. Prevent all oral intake. Provide enteral feedings. A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? Diabetes mellitus Osteomyelitis Malnutrition Alcohol abuse The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? Spiral CT scan Cancer-associated antigen 19-9 Abdominal ultrasound A PET/CT scanWhen caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? Vitamin D Vitamin K Vitamin B Vitamin A Vitamin E The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? "I need to take good care of my belly and ankle skin where it is swollen." "I can use pillows to support my head to help me breathe when I am in bed." "A scrotal support may be more comfortable when I have scrotal edema." "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? "I will need to be checked for chronic HCV and other liver problems." Now that I have had HCV, I will have immunity and not get it again." "I will use care when kissing my wife to prevent giving it to her." "I will need to take adefovir (Hepsera) to prevent chronic HCV. The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? Hepatic structure ultrasound Abdominal girth measurement Serum α-fetoprotein level Ventilation/perfusion scanThe patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? (Vicodin) Tramadol (Percodan) HydromorphoneEXAM #4 A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse’s assessment? The injury results in loss of the reflex arc. There has been a partial transection of the cord. The injury is above the sixth thoracic vertebra. There is a flaccid paralysis of the lower extremities. Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? Escalating tachycardia and shock Paroxysmal hypertension and bradycardia Flaccid paralysis and numbness Absence of sweating and pyrexia The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? Nutritional intake Quadriceps setting Bladder control Use of aids for ambulationA client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer? ABCD A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? Assessing for crepitus Performing neurological assessment Maintaining a patent airway Assessing for bleeding The nurse is caring for a client with a head injury. The Glasgow Coma Scale score of the client is 9. Which nursing intervention should be performed in the client immediately? Control external bleeding with a sterile pressure dressing. Administer oxygen via a non rebreather mask. Intubate the client. Stabilize cervical spine.The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? Monitoring urinary output Immobilizing and stabilizing cervical spine Assessing for other injuries Infusing lactated Ringer solution A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would be the score of the client based on the Glasgow coma scale. Record your answer as a whole number. ________ 11 The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment? Impairment of pupil constriction Impairment of eye movement Inhibition of peripheral vision Inhibition of tear production While caring for a client who sustained a severe head injury in a motor vehicle accident, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client’s condition? Decreased secretion of aldosterone Decreased secretion of atrial natriuretic peptide Decreased secretion of antidiuretic hormone Decreased secretion of parathyroid hormone While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client’s tongue while attempting to talk. Which could be the possible reason for the client’s condition? Damage to the glossopharyngeal nerve Damage to the hypoglossal nerve Damage to the facial nerve Damage to the trigeminal nerveThe registered nurse is caring for a client in the emergency department. Which conditions of the client made the nurse stabilize the cervical spine as the primary nursing intervention? Select all that apply. Blunt abdominal pain Facial chemical burns Flail chest Head injuries Renal colic pain After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? Polyuria and increased specific gravity of urine Hyperkalemia and poor skin turgor Increased blood urea nitrogen (BUN) and hypotension Hyponatremia and decreased urine output A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply. Hyperthermia Decreased level of consciousness Bradycardia Increased weight Nausea and vomiting Decreased serum sodium What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. Instituting fall risk precautions Placing the client in high-Fowler position Providing frequent oral care Restricting fluids to 2 L per day Monitoring for and reporting neurologic changesThe nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis? Presence of pedal edema Preservation of salt Decrease of vasopressin Retention of water A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? fruity odor to the breath Deep respirations Erythema toxicum rash and pruritus Diaphoresis and altered mental state Nervousness and tachycardia The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? Administer insulin glargine subcutaneously at hour of sleep Intravenous administration of 10% dextrose Intravenous administration of regular insulin Maintain nothing prescribed orally (NPO) status The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? "I should administer insulin only if there are any symptoms." "I should keep a daily logbook of times of insulin injection." "I should keep my medication in its original labeled container." "I should see whether the insulin is expired." A healthcare provider's prescription for a client in ketoacidosis is an insulin infusion rate calculated as: Glucose mg/dL ÷ 100 = ____ units/hour. The pharmacy dispensed 100 units regular insulin in 100 mL normal saline and the client's glucose level is 350 mg/dL. At how many milliliters per hour should the nurse set the IV infusion device to administerthe correct amount of medication? Record your answer using one decimal place. _____ mL/hr 3.5 A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? Advance directives Assisted living Monitor for behavioral changes Adult day care Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? Headache and rising blood pressure Decreased level of consciousness or hallucinations Irregular respirations and shortness of breath Abdominal distention and absence of bowel sounds After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness." "Rehabilitation will be more work done by me alone to try to get better." "I want to be rehabilitated for my daughter's wedding in 2 weeks." Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Neurogenic spasticityHypertension Bounding pedal pulses Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? Suctioning of the patient's upper airway Placement of the patient in the Trendelenburg position Administration of benzodiazepines Urinary catheterization A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? Drink more milk Establish bowel evacuation time at bedtime. Use oral laxatives every day. Eat 20-30 g of fiber per day. Drink 1800 to 2800 mL of water or juice. When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Altered patterns of urinary elimination caused by tetraplegia Risk for impairment of tissue integrity caused by paralysis Ineffective airway clearance caused by high cervical spinal cord injury Altered family and individual coping caused by the extent of trauma The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Spinal shock syndrome Brown-Séquard syndromeAnterior cord syndrome Central cord syndrome The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? Provide range-of-motion exercises. Administer enoxaparin (Lovenox). Apply sequential compression boots. Immobilize the fracture preoperatively. This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? The nurse does not have anyone available to accompany the patient. The cast is not dry yet, and it may be damaged while using crutches. Excess edema and other problems are prevented when the leg is elevated for 24 hours. Rest, ice, compression, and elevation are in process to decrease pain. The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? Paresthesia Pitting edemaCompartment syndrome Poor venous return The nurse is planning health promotion teaching for a 45-year-old patient with asthma, low back pain from herniated lumbar disc, and schizophrenia. What does the nurse determine would be the best exercise to include in an individualized exercise plan for the patient? Walking Yoga Weight lifting Calisthenics During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? Poor appetite and aversion to dairy products The presence of bowed legs A measurable loss of height Development of unstable, wide-gait ambulation The nurse is caring for a patient hospitalized with exacerbation of chronic bronchitis and herniated lumbar disc. Which breakfast choice would be most appropriate for the nurse to encourage the patient to check on the breakfast menu? Bran muffin Scrambled eggs Buttered white toast Puffed rice cereal Which nursing intervention is most appropriate when turning a patient following spinal surgery? Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed Elevating the head of bed 30 degrees and having the patient extend the legs while turningPlacing a pillow between the patient's legs and turning the body as a unit Having the patient turn to the side by grasping the side rails to help turn over A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? Allow the patient to dangle legs at the bedside every 2 to 4 hours. Ask the patient about preferred activities to relieve boredom. Perform frequent position changes and range-of-motion exercises. Ambulate the patient to the bathroom every 2 hours. The nurse is admitting a patient who complains of a new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc and lower back pain from other causes, what would be the best question for the nurse to ask the patient? "Is the pain worse in the morning or in the evening?" "Is the pain sharp or stabbing or burning or aching?" "Does the pain radiate down the buttock or into the leg?" "Is the pain totally relieved by analgesics, such as acetaminophen (Tylenol)?" The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis.The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-year-old patient who has low back pain from a herniated lumbar disc. What would be an appropriate nursing intervention to treat this problem? Elevate the head of the bed 20 degrees and flex the knees. Place a small pillow under the patient's upper back to gently flex the lumbar spine. Place the bed in reverse Trendelenburg with the feet firmly against the footboard. Provide gentle ROM to the lower extremities. The nurse has reviewed proper body mechanics with a patient with a history of low back pain caused by a herniated lumbar disc. Which statement made by the patient indicates a need for further teaching? "I should exercise at least 15 minutes every morning and evening." "I should try to keep one foot on a stool whenever I have to stand for a period of time." "I should pick up items by leaning forward without bending my knees." "I should sleep on my side or back with my hips and knees bent." When reinforcing health teaching about the management of osteoarthritis (OA), the nurse determines that the patient needs additional instruction after making which statement? "I can use a cane if I find it helpful in relieving the pressure on my back and hip." "I should try to stay standing all day to keep my joints from becoming stiff." "I should take the Naprosyn as prescribed to help control the pain." "A warm shower in the morning will help relieve the stiffness I have when I get up." A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Obtain comprehensive dental care. Maintain hemoglobin A1c below 7%. Avoid sick people and wash hands. Coughing and deep breathing with splintingA 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes. Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased high-density lipoproteins (HDL) Increased triglyceride levels Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL) A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take?Eat a piece of pizza. Eat 15 g of simple carbohydrates Take an extra dose of rapid-acting insulin. Drink some diet pop. The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Washes hands with soap and water to cleanse the site to be used. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes. Warms the finger before puncturing the finger to obtain a drop of blood. Chooses a puncture site in the center of the finger pad. The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels Assessing the patient's white blood cell levels and assessing for infection Monitoring the patient's level of consciousness and assessing for acute delirium or agitation The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate? The patient should report any decrease in urinary elimination to the health care provider. The patient can expect to experience weight loss resulting from increased diuresis The patient should alternate nostrils during administration to prevent nasal irritation. The patient should monitor for symptoms of hypernatremia as a side effect of this drug.The nurse should monitor for increases in which laboratory value for the patient as a result of being treated with dexamethasone (Decadron)? Potassium Sodium Calcium Blood glucose The patient has an order to receive 45 mg of prednisone by mouth daily. Available are 10 mg tablets. How many tablets should the nurse prepare to give? _______ tablets 4.5 What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? Closely monitoring the patient's intake and output Patient teaching related to levothyroxine (Synthroid) Providing a dark, low-stimulation environment Patient teaching related to radioactive iodine therapy During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do for the patient? Administer antiemetic medications. Administer a blood transfusion. Administer hypertonic saline. Decrease the rate of fluid removal. Which statement by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? "It is important for you to maintain a daily written record of blood pressure and weight." "It is essential that you maintain aseptic technique to prevent peritonitis." "You will need to continue regular medical and nursing follow-up visits while performing CAPD." "You will be allowed a more liberal protein diet once you complete CAPD."The nurse preparing to administer a dose of calcium acetate (PhosLo) to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? Potassium Sodium Magnesium Phosphorus An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. ______ gtts/min 38 While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse’s conclusion? Systolic blood pressure is 120 mm Hg Pulse pressure is 40 mm Hg Blood osmolality is 280 milliosmoles per kg Urine output is 25 mL per hr A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Skin turgor Client's report about fluid intake Intake and output results Blood lab resultsThe nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority? ABCD A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication. Check the compatibility of the medication and the continuous IV solution. Flush the client's venous access device to ensure patency. Disconnect the continuous IV solution while administering the piggyback medication.A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr 35 The nurse who is working during the 8:00 am to 4:00 pm shift must document a client’s fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number. ___mL 970 What should a nurse assess after applying a body jacket brace to a client with severe spine injuries following a car accident? Select all that apply. Abdomen for decreased bowel sounds Areas of pressure over the bony prominences Development of cast syndrome Signs of compartment syndrome Pin sites A critically injured client was brought to the hospital following a car accident and the client should be immediately triaged for determining the nature and acuity of the injuries. Who is delegated to perform the task? Nurse manager Primary healthcare provider Licensed practical nurse Registered nurseWhat is the action of vasopressin? Stimulates bone marrow to make red blood cells Promotes sodium reabsorption Reabsorbs water into the capillaries Promotes tubular secretion of sodium What is the action of the vasopressin hormone released from the client’s posterior pituitary? Helps produce concentrated urine Enhances sodium reabsorption in the distal convoluted tubule Causes tubular secretion of sodium Promotes potassium secretion in the collecting duct The primary health care provider prescribed tolvaptan to a client whose laboratory reports reveal low plasma osmolarity and continued secretion of vasopressin from syndrome of inappropriate antidiuretic hormone. During follow-up care, which finding in the client indicates a side effect of medication? Increased urine osmolarity Increased demyelination of brain neurons Decreased hyponatremia Decreased deep tendon reflexes