NURSING LP N 100 ATI Med-Surg (Multiple Response) | Download To Score An A

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ATI Med-Surg Test s-Multiple Response 1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.) 1) Dyspnea 2... ) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations INCORRECT 5) Bradycardia Answer Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange in the lungs. Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from these chronic low blood- oxygen levels. Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations become increasingly shallow and more rapid. Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being delivered to the tissues. 2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) 1) Buffalo hump 2) Purple striations 3) Moon face INCORRECT 4) Tremors INCORRECT 5) Obese extremities Answer Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who have this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism. 3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Encourage fluid intake. 2) Monitor the puncture site for hematoma. INCORRECT 3) Insert a urinary catheter. INCORRECT 4) Elevate the client’s head of bed. INCORRECT 5) Apply a cervical collar to the client. Answer Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache. Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the insertion site because this can indicate bleeding. Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion. Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk for a headache. Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client. 4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.) 1) Decreasing anxiety 2) Controlling emesis INCORRECT 3) Relaxing skeletal muscles INCORRECT 4) Preventing surgical site infections 5) Reducing the amount of narcotics needed for pain relief Answer Rationale: Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with moderate anxiety. Controlling emesis is correct. The nurse should include that hydroxyzine is an effective antiemetic and is used to control nausea and vomiting in pre- and postoperative clients. Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as diazepam (Valium), are used to produce skeletal muscle relaxation. Preventing surgical site infections is incorrect. The nurse should instruct the client that antibiotics administered prior to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does not have any effect on bacteria. Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should instruct the client that when it is used for surgical clients, narcotic requirements may be significantly reduced. 5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.) INCORRECT 1) Polyuria 2) Blurry vision 3) Tachycardia INCORRECT 4) Polydipsia 5) Sweating Answer Rationale: Polyuria is incorrect. Hyperglycemia causes polyuria. Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and hypotension. Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety, irritability, headache, and hypotension. Polydipsia is incorrect. Hyperglycemia causes polydipsia. Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety, irritability, headache, and hypotension. 6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.) 1) Edema 2) Erythema 3) Tophi 4) Tight skin INCORRECT 5) Symmetrical joint pain Answer Rationale: Edema is correct. Swelling over the affected joints is a classic manifestation of gout. Erythema is correct. Redness over the affected joints is a classic manifestation of gout. Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in subcutaneous tissue due to the accumulation of urate crystals. Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout. Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid arthritis, not gout. 7. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.) 1) Perform leg exercises every 2 hr. 2) Encourage hourly use of an incentive spirometer while awake. 3) Document the color, consistency, and amount of nasogastric drainage. INCORRECT 4) Irrigate the nasogastric tube every 4 to 8 hr. INCORRECT 5) Maintain bed rest for 48 hr following surgery. Answer Rationale: Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg exercises, independently or with assistance, to prevent skin breakdown.Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients should be encouraged to use the incentive spirometer ten times each hour while awake to prevent atelectasis.Document the color, consistency, and amount of nasogastric drainage is correct. Documenting the color, consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of care.Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG tube should not be moved or irrigated unless prescribed by the provider.Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not be included in the plan of care. Early ambulation prevents distention and improves intestinal mobility. 8. A nurse is assisting with discharge teaching for a client who is postoperative following a laryngectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) 1) To aid in swallowing food, tip the chin before swallowing. INCORRECT 2) Avoid using liquid supplements. INCORRECT 3) Include warm foods in your diet because they are easier to swallow. 4) Swallow twice after each bite. INCORRECT 5) Take a sip of water with each bite of food. Answer Rationale: To aid in swallowing food, tip the chin before swallowing is correct. This action decreases the risk of aspiration. Avoid using liquid supplements is incorrect. Following a laryngectomy, the client is at risk for malnutrition. Liquid supplements provide needed protein and calories. Include warm foods in your diet because they are easier to swallow is incorrect.The client should include cold foods in her diet because they are easier to swallow. Swallow twice after each bite is correct. Swallowing once when initially propelling food down the esophagus and a second time (dry swallowing) to fully clear the esophagus of food will decrease the risk of aspirating food left in the esophagus. Take a sip of water with each bite of food is incorrect. This action places the client at risk for aspiration. 9. A nurse is assisting with discharge teaching for a client who is postoperative from a mastectomy including the removal of axillary lymph nodes. Which of the following instructions should the nurse include? (Select all that apply.) INCORRECT 1) Use talcum powder instead of deodorant on the affected side for the first two weeks after surgery. 2) Perform range-of-motion exercises of the affected arm. INCORRECT 3) Avoid lifting arm above shoulder level on the affected side. INCORRECT 4) Wait 72 hr before consuming a regular diet. 5) Elevated the affected arm on a pillow when resting in bed. Answer Rationale: Use talcum powder instead of deodorant on the affected side for the first two weeks after surgery is incorrect. The client should avoid the use of talcum powder and deodorant until the incision is healed. Perform range-of-motion exercises of the affected arm is correct. The client should perform range-of-motion exercises on the affected arm to improve circulation and reduce the risk of lymphedema. Avoid lifting arm above shoulder level on the affected side is incorrect. The client should face a wall with the arms slightly bent and “walk” both arms up the wall as high as possible. Wait 72 hr before consuming a regular diet is incorrect. The client can eat a regular diet 24 hr after surgery. Elevated the affected arm on a pillow when resting in bed is correct. The client should elevate the affected arm to increase circulation and reduce the risk of lymphedema. 10. A client who is postoperative returns to the unit in skeletal traction. When collecting data from the client, the nurse should expect which of the following findings? (Select all that apply.) 1) Redness at the pin sites 2) Warmth at the pin sites INCORRECT 3) Movement of the pins at the insertion sites INCORRECT 4) No drainage from the pin sites INCORRECT 5) Tenting of the skin around the pin sites Answer Rationale: Redness at the pin sites is correct. The nurse should expect the client to have redness at the pin sites, as it is a manifestation of the expected reaction after insertion. Warmth at the pin sites is correct. The nurse should expect the client to have warmth at the pin sites, as it is a manifestation of the expected reaction after insertion. Movement of the pins at the insertion sites is incorrect. The nurse should report movement of the pins to the surgeon immediately, as it is a manifestation of infection. No drainage from the pin sites is incorrect. Up to 72 hr after surgery, serosanguineous drainage from the pin sites can be heavy; therefore, it is important to clean the pin sites daily. Tenting of the skin around the pin sites is incorrect. The nurse should report tenting to the surgeon immediately, as it is a manifestation of infection. 11. A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply.) INCORRECT 1) "I will lie down for one half hour after meals." 2) "I will consume less caffeine and spicy foods." 3) "I will sleep with the head of my bed elevated." 4) "I will try not to gain weight." INCORRECT 5) "I will drink less fluid." Answer Rationale: “I will lie down for one half hour after meals.” is incorrect. A client who has a hiatal hernia should remain upright for at least 1 hr after meals and preferably for several hours. “I will consume less caffeine and spicy foods.” is correct. These foods and beverages can worsen the symptoms of a hiatal hernia. “I will sleep with the head of my bed elevated.” is correct. The client should raise the head of the bed on blocks to avoid lying flat when sleeping. “I will try not to gain weight.” is correct. Obesity raises intra-abdominal pressure and makes the hernia worse. “I will drink less fluid.” is incorrect. Clients should consume adequate and appropriate amounts of fluid, whether or not they have a hiatal hernia. 12. A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) INCORRECT 1) Orthopnea INCORRECT 2) Headache 3) Nausea 4) Tachycardia 5) Diaphoresis Answer Rationale: Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from a myocardial infarction, but it is not a common manifestation of acute MI. Headache is incorrect. Chest pain and sometimes jaw and shoulder pain, not headache, are classic manifestations of acute MI. Nausea is correct. Nausea and vomiting are classic manifestations of acute MI. Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI. Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI. 13.A nurse is reinforcing nutrition teaching for a client who has chronic kidney disease about limiting foods high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply). 1) Orange juice INCORRECT 2) Watermelon 3) Bananas INCORRECT 4) Corn flakes cereal INCORRECT 5) White rice Answer Rationale: Orange juice is correct. Orange juice is high in potassium; 240 mL (8 oz) contains 496 mg of potassium Watermelon is incorrect. Watermelon is low in potassium; 152 g (1 cup) of diced watermelon contains 170 mg of potassium. Bananas is correct. Bananas are high in potassium; one medium banana contains 422 mg of potassium. Corn flakes cereal is incorrect.Corn flakes cereal is low in potassium; 34 g (1 cup) of corn flakes cereal contains 60 mg of potassium. White rice is incorrect. White rice is low in potassium; 158 g (1 cup) of cooked white rice contains 55 mg of potassium. 14.A nurse is reinforcing nutrition teaching to a client who has chronic kidney disease about limiting foods high in phosphorus. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply). 1) Milk 2) Sunflower seeds INCORRECT 3) Orange juice INCORRECT 4) Frozen kale 5) Poultry Answer Rationale: Milk is correct. All animal products, including dairy, are a source of phosphorus and should be avoided by a client who is on a phosphorus restricted diet. Sunflower seeds is correct. Sunflower seeds are a food source high in phosphorus and should be avoided by a client who is on a phosphorus restricted diet. Orange juice is incorrect. Orange juice is not a food source high in phosphorus and is safe for clients on a phosphorus restricted diet. Frozen kale is incorrect. Frozen kale is not a food source high in phosphorus and is safe for clients on a phosphorus restricted diet. Poultry is correct. All animal products, including poultry, are a source of phosphorus and should be avoided by a client who is on a phosphorus restricted diet. 15.A nurse is assisting in the plan of care for a client who is scheduled to have a renal biopsy. Which of the following actions should the nurse include in the plan? (Select all that apply). 1) Collect a urine specimen prior to the procedure. 2) Obtain an informed consent prior to the procedure. INCORRECT 3) Administer diphenhydramine prior to the procedure. INCORRECT 4) Maintain a clear liquid diet 4 hr prior to the procedure. 5) Complete coagulation studies prior to the procedure. Answer Rationale: Collect a urine specimen prior to the procedure is correct. A urine specimen is needed prior to the procedure to allow for postprocedure comparison. Obtain an informed consent is correct. Because the procedure is invasive it requires written, informed consent. Administer diphenhydramine prior to the procedure is incorrect. Benadryl is sometimes used prior to a procedure that uses dye, but not for a renal biopsy. Maintain a clear liquid diet 4 hr prior to the procedure is incorrect. NPO for 6 to 8 hr prior to the procedure is usually required. Complete coagulation studies prior to the procedure is correct. Coagulation studies are obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site. 16. A nurse is caring for a client following a renal biopsy. Which of the following actions should the nurse take? (Select all that apply). 1) Monitor for hematuria. 2) Check for flank pain. INCORRECT 3) Observe for extravasation of tissue surrounding the biopsy site. INCORRECT 4) Encourage ambulation. INCORRECT 5) Administer aspirin PRN for pain. Answer Rationale: Monitor for hematuria is correct. The nurse should monitor the client for bleeding, such as hematuria, tachycardia, hypotension, or bleeding at the biopsy site. Check for flank pain is correct. Flank pain is a manifestation of internal bleeding from the renal biopsy. Observe for extravasation of tissue surrounding the biopsy site is incorrect. Extravasation is associated with the infiltration of dye or medication around an IV site and is not a risk following a renal biopsy. Encourage ambulation is incorrect. The client should be on strict bedrest following a renal biopsy. Administer aspirin PRN for pain is incorrect. Aspirin is contraindicated for a client who is postoperative renal biopsy due to the increased risk for bleeding. 17.A nurse is reinforcing preoperative teaching to a client who is to undergo a radical prostatectomy. Which of the following statements should the nurse include in the teaching? (Select all that apply). 1) "You may feel the need to urinate even though a catheter is in place." 2) "Performing Kegel exercises following the surgery will help you to manage incontinence." INCORRECT 3) "There is very little postoperative pain with this procedure." INCORRECT 4) "You will be on a low-fiber diet following the surgery." 5) "You should expect your urine to be blood-tinged for a few days following the surgery." Answer Rationale: ”You may feel the need to urinate even though a catheter is in place.” is correct. Pressure from the taping of the catheter to the thigh or abdomen may cause the sensation of the need to void. “Performing Kegel exercises following the surgery will help you to manage incontinence.” is correct. Urinary incontinence is a common complication following a radical prostatectomy. Kegel exercises can reduce the severity of the incontinence. “There is very little postoperative pain with this procedure.” is incorrect. Along with incisional pain, the client may also experience pain from bladder spasms. Clients are often provided a patient-controlled analgesia pump for the first 24 hr postoperative period. “You will be on a low-fiber diet following the surgery.” is incorrect. Straining with defecation can lead to postoperative bleeding. A high-fiber diet and a stool softener are often prescribed. “You should expect your urine to be blood-tinged for a few days following the surgery.” is correct. The flow of bladder irrigation is maintained to keep the urine a reddish pink, which should clear to a pink tinge within 48 hr following surgery. Urine which turns bright red indicates bleeding and should be reported immediately. 18. A nurse is reinforcing teaching about possible treatments with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? (Select all that apply.) 1) Tar preparations 2) Corticosteroids 3) Ultraviolet light therapy INCORRECT 4) Laser therapy INCORRECT 5) Topical antibiotics Answer Rationale: Tar preparations is correct. Tar preparations help to impede the proliferation of skin cells and are effective to remove scales as well as increase remission. Corticosteroids is correct. Corticosteroids help reduce the inflammation and pruritus associated with psoriasis. Ultraviolet light therapy is correct. Ultraviolet light therapy is effective in the treatment of psoriasis by decreasing the growth rate of epidermal cells. Laser therapy is incorrect. Laser therapy is appropriate for the removal of skin lesions rather than for the treatment of psoriasis. Topical antibiotics is incorrect. Antibiotics are not appropriate for the treatment of psoriasis, as it is not a bacterial condition. 19. A nurse is assisting in planning an educational session regarding risk factors for skin cancer to a group of clients. Which of the following information should the nurse plan to include in the session? (Select all that apply.) INCORRECT 1) Being dark-skinned INCORRECT 2) Age under 40 years 3) Overexposure to ultraviolet light 4) Chronic skin irritations 5) Genetic predisposition Answer Rationale: Being dark-skinned is incorrect. Light-skinned individuals are at greater risk for developing skin cancer. Age under 40 years is incorrect. Individuals between the ages of 30 and 60 are at the greatest risk for developing nonmelanoma skin cancers. Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Rays from the sun are known to be carcinogenic and can result in malignant changes. Chronic skin lesions is correct. Chronic skin lesions are a risk factor for developing skin cancer. Clients are taught to monitor for a change in these chronic lesions as a precursor to a malignancy. Genetic predisposition is correct.Genetic predisposition is a risk factor for developing skin cancer, particularly malignant melanoma. 20.A nurse is reinforcing teaching with a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should she include in the teaching? (Select all that apply). 1) Cryosurgery 2) Electrodessication 3) Radiation therapy INCORRECT 4) Photochemotherapy 5) Mohs surgery Answer Rationale: Cryosurgery is correct. Cryosurgery freezes the cancerous tissue and is used in the treatment of BCC. Electrodessication is correct. Electrodessication uses electrical energy to destroy and remove cancerous tissue and is used in the treatment of BCC. Radiation therapy is correct. Radiation therapy can be used in the treatment of BCC depending on client age and the location of the tumor. Photochemotherapy is incorrect. Photochemotherapy is used in the treatment of psoriasis rather than BCC. Mohs surgery is correct. Mohs micrographic surgery is used in the treatment of BCC as the most accurate method of removing the tumor while preserving healthy tissue. 21. A nurse is collecting data for a client who has giant cell arteritis. Which of the following findings should the nurse expect? (Select all that apply.) 1) Chest pain 2) Loss of vision INCORRECT 3) Weight gain 4) Dyspnea 5) Headache Answer Rationale: Chest pain is correct. Chest pain is a finding associated with giant cell arteritis because of the inflammation of the coronary arteries that can occur. Loss of vision is correct. Loss of vision is a finding associated with giant cell arteritis because of the inflammation that can occur with the vessels of the eyes. Weight gain is incorrect. Weight loss can occur because of the inflammatory process and metabolic process. Dyspnea is correct. Dyspnea is a finding associated with giant cell arteritis that may occur with inflammation of the pulmonary arteries.Headache is correct. Headache is a finding associated with giant cell arteritis that may occur with inflammation of the cranial arteries. 22. A nurse is collecting data from a client who has a herniated intervertebral cervical disc. Which of the following findings should the nurse expect? (Select all that apply.) 1) Tingling in the arms INCORRECT 2) Low back pain 3) Shoulder pain INCORRECT 4) Hip pain 5) Neck stiffness Answer Rationale: Tingling in the arms is correct. Numbness and tingling in the upper extremities are common findings of a herniated cervical intervertebral disc.Low back pain is incorrect. Low back pain with muscle spasms is a common finding of a herniated lumbar intervertebral disc.Shoulder pain is correct. Shoulder pain, particularly on the top of the shoulders, is a common finding of a herniated cervical intervertebral disc.Hip pain is incorrect. Hip pain is a common finding of a herniated lumbar intervertebral disc. Neck stiffness is correct. Stiffness and pain in the neck are common findings of a herniated cervical intervertebral disc. 23. A nurse is collecting data from a client who has Paget's disease. Which of the following findings should the nurse expect? (Select all that apply.) 1) Cranial enlargement 2) Skeletal pain 3) Waddling gait INCORRECT 4) Cold extremities INCORRECT 5) Muscle weakness Answer Rationale: Cranial enlargement is correct. When the skull is involved, Paget's disease causes thickening and enlargement of the skull bones and enlargement of the cranium.Skeletal pain is correct. Paget's disease causes pain and tenderness over the affected bones.Waddling gait is correct. When the legs are involved, Paget's disease causes bowing of the legs and a waddling gait.Cold extremities is incorrect. Paget's disease causes warmth over the affected bones.Muscle weakness is incorrect. The nurse should expect muscle weakness for a client who has osteomalacia. 24. An occupational health nurse is instructing workers at an industrial facility about emergency procedures to follow in the event of a traumatic amputation. Which of the following guidelines should the nurse include about preserving the amputated part for possible surgical reattachment? (Select all that apply.) 1) Wrap the part in sterile gauze. INCORRECT 2) Place the severed end of the part directly into crushed ice. 3) Put the severed part in a plastic bag. INCORRECT 4) Scrub the severed part with antibacterial solution. 5) Prevent the severed part from coming in contact with water. Answer Rationale: Wrap the part in sterile gauze is correct. The person at the scene should wrap the severed part in sterile gauze or a clean cloth, and soak it with saline solution, if available.Place the severed end of the part directly into crushed ice is incorrect. The person at the scene should not allow direct contact between the part and ice.Put the severed part in a plastic bag is correct. The person at the scene should place the severed part in a sealed, waterproof plastic bag and then put the bag in ice water.Scrub the severed part with antibacterial solution is incorrect. The person on the scene should only rinse the amputated part if needed to remove visible debris.Prevent the severed part from coming in contact with water. The person at the scene should not allow the severed part to become wet but should keep it dry. 25. A nurse in a provider’s office is reinforcing teaching with a client about the risk factors for osteoarthritis. Which of the following information should the nurse include? (Select all that apply.) INCORRECT 1) Bacterial infections INCORRECT 2) Use of diuretic medications 3) Aging 4) Obesity 5) Heredity Answer Rationale: Bacteria is incorrect. Bacterial infections can lead to infectious arthritis or rheumatoid arthritis, but it is not a risk factor for osteoarthritis. Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for osteoarthritis. Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the body’s weight over time. Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body’s weight over time. Heredity is correct. There is a genetic component to the development of osteoarthritis. 26. A nurse in a provider’s office is reinforcing teaching with a female client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply.) 1) Sedentary lifestyle INCORRECT 2) Obesity 3) Aging 4) Excessive caffeine INCORRECT 5) Hormone therapy Answer Rationale: Sedentary lifestyle is correct. Immobility depletes bone. Obesity is incorrect. Women who are obese have a greater capacity for storing estrogen to help maintain acceptable levels of calcium. Aging is correct. Women lose bone due to estrogen depletion after menopause. Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine. Hormone therapy is incorrect. Estrogen protects women from developing osteoporosis. 27. A nurse is instructing coworkers about how to minimize lower back pain and avoid repeated episodes of back pain. Which of the following strategies should the nurse include? (Select all that apply.) 1) Avoid prolonged sitting. INCORRECT 2) Apply cold packs frequently. 3) Do partial sit-ups with the knees bent. INCORRECT 4) Sleep on a soft mattress. 5) Ask for help when moving clients. Answer Rationale: Avoid prolonged sitting is correct. Staying in any one position for too long, even lying down, can worsen back pain. Changing positions frequently is essential. Apply cold packs frequently is incorrect. For back pain, the nurse should recommend heat, but for no longer than 30 min at a time to prevent rebound effects. Do partial sit-ups with the knees bent is correct. Exercises that strengthen back muscles and help prevent pain include partial sit-ups with the knees bent, knee-chest exercises, and pelvic tilts. Sleep on a soft mattress is incorrect. The recommendation is to sleep on a firm mattress for good back support. Ask for help when moving clients is correct. The nurse should remind coworkers to use good body mechanics when handling clients and never to attempt lifting or moving clients by themselves. 28. A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.) 1) Inspiratory stridor 2) Cyanosis INCORRECT 3) Muscle tremors 4) Retractions INCORRECT 5) Nausea Answer Rationale: Inspiratory stridor is correct. The client who has an obstruction of the airway may exhibit inspiratory stridor as the inspired air is partially blocked.Nausea is incorrect. Gastrointestinal upset may occur in response to antibiotic therapy used to treat the respiratory infection. However, it is not an indication of impending airway obstruction.Retractions is correct. Substernal, suprasternal, and intercostal retractions as well as flaring nares are indications of an impended or obstructed airway.Muscle tremors is incorrect. Muscle tremors may occur in a client who has an electrolyte imbalance. However, they are not an indication of an airway obstruction.Cyanosis is correct. The client who has an airway obstruction may become cyanotic due to a lack of oxygen transfer to the cells. Other manifestations include coughing and labored respirations. 29. A nurse is reinforcing teaching with the parent of a school-age client who has asthma about the use of a peak flow meter. Which of the following statements about the yellow zone should the nurse include in the teaching? (Select all that apply.) 1) The child should increase his routine medications. 2) The child is having an exacerbation of the asthma. INCORRECT 3) The child is blowing too hard into the meter. INCORRECT 4) The child needs to go to the hospital. INCORRECT 5) The child can participate in strenuous physical activity. Answer Rationale: The child should increase his routine medications is correct. A peak flow reading in the yellow zone indicates a decrease in airflow. The child should increase the prescribed routine medications and recheck the peak flow rate several minutes after using a relief medication.The child is having an exacerbation of the asthma is correct. A peak flow reading in the yellow zone signals that usual airflow has decreased, indicating an exacerbation of the asthma.The child is blowing too hard into the meter is incorrect. A reading in the yellow zone is an indication that the child’s breathing is less than baseline measures. In order to use a peak flow meter, the child should blow into the device as hard and quickly as possible.The child needs to go to the hospital is incorrect. A child whose peak flow is in the yellow zone should increase his prescribed medication and recheck the peak flow rate. A child with a red zone reading needs to go to the hospital if he is still in the red zone after taking his medications.The child can participate in strenuous physical activity. A child whose peak flow rate is in the green zone can perform his usual activities. A child whose rate is in the yellow zone can perform some activities. However, he will be limited in the amount of physical exertion he can expend because this may aggravate his shortness of breath and further exacerbate the asthma symptoms. 30. A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) INCORRECT 1) Genetic predisposition 2) Hypercholesterolemia 3) Hypertension 4) Obesity 5) Smoking Answer Rationale: Genetic predisposition is incorrect. Although it is a risk factor for heart disease, clients cannot change their genetic predisposition; therefore it is not a modifiable risk factor. Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase clients’ risk for heart disease, and they can change these levels. Hypertension is correct. Although it may not always be possible to eliminate hypertension, clients can change their blood pressure levels and thus reduce their risk for cardiovascular disease. Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting smoking. 31. A nurse is reinforcing teaching with a class about preventing deep-vein thrombosis. The nurse should include in the teaching that which of the following is a risk factor for this disorder? (Select all that apply.) 1) Dehydration 2) Oral contraceptive use INCORRECT 3) Hypertension INCORRECT 4) High calcium intake 5) Immobility Answer Rationale: Dehydration is correct. Dehydration increases the blood's viscosity, thus increasing the risk for clot formation.Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives.Hypertension is incorrect. Hypertension does not increase the risk for clot formation.High calcium intake is incorrect. High calcium intake does not increase the risk for clot formation.Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation. 32. A nurse is assisting with the care of a client who is postoperative following a cardiac catheterization via the femoral artery. Which of the following actions should the nurse take? (Select all that apply.) 1) Check peripheral pulses in the affected extremity. INCORRECT 2) Place the client in high-Fowler's position. INCORRECT 3) Measure the client's vital signs every 8 hr. 4) Keep the client's hip and leg extended. 5) Have the client remain in bed up to 6 hr. Answer Rationale: Check peripheral pulses in the affected extremity is correct. The nurse should check peripheral pulses, skin temperature, and color in the affected extremity.Place the client in high-Fowler's position is incorrect. The client should remain flat for 6 hr following the procedure.Measure the client's vital signs every 8 hr is incorrect. The nurse should measure the client's vital signs every 15 min for the first hr, every 30 min for 2 hr or until stable, and then every 1 hr until stable.Keep the client's hip and leg extended is correct. Preventing the leg and hip from flexing helps promote clot formation.Have the client remain in bed up to 6 hr is correct. The client should remain flat in bed for 6 hours following a cardiac catheterization via the femoral artery. 33. A nurse is reinforcing teaching for a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) 1) Count your pulse for 1 min each morning. INCORRECT 2) Count your respiratory rate for 1 min each morning. 3) Report hiccups to the provider. INCORRECT 4) Avoid metal detectors. INCORRECT 5) Do not operate microwave ovens. Answer Rationale: Count your pulse for 1 min each morning is correct. Clients who have a permanent pacemaker should count their heart rate daily, document the information, and report changes.Count your respiratory rate for 1 min each morning is incorrect. There is no need for clients who have a permanent pacemaker to record their respiratory rate.Report hiccups to the provider is correct. The client should report any indication the pacemaker is not functioning correctly, such as hiccups.Avoid metal detectors is incorrect. There is no danger to the client in going through a metal detector, but the client should inform airport personnel because the pacemaker will trigger an alarm.Do not operate microwave ovens is incorrect. It is safe for clients who have a pacemaker to operate microwave ovens unless the pacemaker is old and does not have the appropriate shielding or is defective. 34. A nurse is caring for a client who has a surgical wound. Which of the following factors places the client at risk for dehiscence? (Select all that apply.) 1) Poor nutritional state INCORRECT 2) Altered mental status 3) Obesity INCORRECT 4) Pain medication administration 5) Wound infection Answer Rationale: Poor nutritional state is correct. The client who is malnourished is at risk for dehiscence due to impaired healing. Altered mental status is incorrect. The client who has an altered mental status is not at risk for dehiscence. Obesity is correct. The client who is obese is at risk for dehiscence due to poor healing abilities of adipose tissue and the constant strain placed on the incision. Pain medication administration is incorrect. The client who is taking pain medication is not at risk for dehiscence. Wound infection is correct. The client who has a wound infection is at risk for dehiscence due to delayed healing. 35. A nurse is contributing to the plan of care for a client who has cirrhosis of the liver. Which of the following interventions should the nurse include in the plan? (Select all that apply.) 1) Implement fall precautions. INCORRECT 2) Obtain a weekly weight. 3) Initiate a low sodium diet. 4) Measure abdominal girth daily. INCORRECT 5) Administer enemas to manage constipation. Answer Rationale: Implement fall precautions is correct. The client who has cirrhosis of the liver has an increased risk of changes in mental status and confusion due to increased levels of serum ammonia and hepatic encephalopathy, which place the client at increased risk for falls.Obtain a weekly weight is incorrect. The client who has cirrhosis also has impaired salt and fluid regulation leading to fluid overload. Obtaining a daily weight would be an intervention that allows the nurse to more closely monitor fluid status.Initiate a low sodium diet is correct. The client who has cirrhosis also has impaired salt and fluid regulation leading to fluid overload. Regulating sodium intake by placing the client on a low sodium diet will assist in minimizing water retention.Measure abdominal girth daily is correct. The client who has cirrhosis develops fluid retention that manifests as ascites in the abdomen. Measuring abdominal girth daily is one measure the nurse can use to monitor fluid status.Administer enemas to manage constipation is incorrect. The client who has cirrhosis is at an increased risk for bleeding due to a lack of vitamin K and a low platelet levels. The nurse should place the client on bleeding precautions, which would exclude the use of enemas and intramuscular injections. 36. A nurse is reinforcing teaching with a female client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.) 1) Lubricate lips with water-soluble ointment. 2) Brush teeth with a soft toothbrush. 3) Blow nose gently. INCORRECT 4) Limit fruit consumption. INCORRECT 5) Manage constipation with the use of glycerin suppositories. Answer Rationale: Lubricate lips with water-soluble ointment is correct. The nurse should recognize that the client who has thrombocytopenia is at risk for bleeding and should instruct the client to lubricate lips with water-soluble ointment to avoid cracking, which may result in spontaneous bleeding from the site.Brush teeth with a soft toothbrush is correct. The nurse should instruct the client to brush teeth with a soft toothbrush to avoid spontaneous bleeding of the gums. The nurse should also reinforce that flossing should be avoided, as this can increase the risk of bleeding.Blow nose gently is correct. The nurse should instruct the client to blow the nose gently to minimize spontaneous bleeding from the nares.Limit fruit consumption is incorrect. The nurse should reinforce teaching that fruit consumption will not affect the bleeding risk of the client who has thrombocytopenia.Manage constipation with the use of glycerin suppositories is incorrect.The nurse should instruct the client to avoid inserting anything into the rectum, vagina, or urinary tract, as this can result in internal bleeding in the client who has thrombocytopenia. A high-fiber diet and fluids along with activity can prevent the development of constipation. The nurse should instruct the client to avoid bearing down excessively when trying to have a bowel movement, as this also may cause spontaneous bleeding of the rectal tissues. 37. A nurse is reinforcing discharge teaching with a client who is immunocompromised. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) 1) Drink 6 to 8 glasses of chilled tap water each day. 2) Restrict visitor with active infections. INCORRECT 3) Limit the client from bathing daily. 4) Instruct the client to eat cooked foods only. INCORRECT 5) Clean the toothbrush by placing it under hot running water. Answer Rationale: Drink 6 to 8 glasses of chilled tap water each day is incorrect. The nurse should encourage the client to drink adequate amounts of fluid. However, the client who is immunocompromised should drink only bottled water to minimize the risk of ingesting pollutants and bacteria that may be present in the tap water. Restrict visitor with active infections is correct. The nurse should instruct the client to restrict visitors with an active infection to protect the client from contacting an infection due to the suppressed immune system. Limit the client from bathing daily is incorrect. The nurse should have the client bathe daily with an anti-microbial soap to clean bacteria off of skin that might cause an infection. Instruct the client to eat cooked foods only is correct. The nurse should instruct the client eat cooked foods only to protect the client from contracting an infection from bacteria present on raw or undercooked food. Clean the toothbrush by placing it under hot running water. The nurse should instruct the client to clean the toothbrush frequently to decrease the risk of infection from oral bacteria. This should be accomplished by running the toothbrush through the dishwasher or soaking it in a solution of bleach or hydrogen peroxide. 38. A nurse is reviewing the laboratory data of a client who has acute leukemia and received aggressive chemotherapy treatment 10 days ago. Which of the following abnormalities should the nurse expect to see? (Select all that apply.) 1) Decreased platelet count INCORRECT 2) Increased hemoglobin count 3) Decreased WBC count INCORRECT 4) Increased creatinine kinase level 5) Decreased RBC count Answer Rationale: Decreased platelet count is correct. The nurse should expect to see a decreased platelet count due to bone marrow suppression from the chemotherapy treatment.Increased hemoglobin count is incorrect. The nurse should expect to see a decreased hemoglobin count, not increased, due to bone marrow suppression from the chemotherapy treatment.Decreased WBC count is correct. The nurse should expect to see a decreased WBC count due to bone marrow suppression from the chemotherapy treatment.Increased creatinine kinase level is incorrect. The nurse should not expect to see an increase in the client’s creatinine kinase level. The client may experience muscle aches, but chemotherapy does not result in muscle damage.Decreased RBC count is correct. The nurse should expect a decreased RBC count due to bone marrow suppression from the chemotherapy treatment. 39. A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply.) 1) Encourage fluid intake. 2) Apply elastic compression stockings. 3) Encourage frequent leg exercises. 4) Measure thighs. INCORRECT 5) Massage calves. Answer Rationale: Encourage fluid intake is correct. The nurse should recognize that one of the factors increasing the risk for the development of a DVT is dehydration. Encouraging the client to increase fluid intake will help minimize the risk for the development of a DVT.Apply elastic compression stockings is correct. The nurse should recognize that elastic compression stockings decrease venous stasis and are used prophylactically to prevent DVT formation.Encourage frequent leg exercises is correct. The nurse should identify that one of the ways to prevent DVT formation is to enhance the blood flow through the lower extremities. One means of doing this is through exercising the lower extremities using quadriceps and gluteal sets as well as ankle flexion and extension.Measure thighs is correct. The nurse should recognize the manifestations of a DVT include redness, swelling, warmth and pain of the affected extremity. Measuring calf and thigh diameters daily will assist in the identification of a DVT should one develop.Massage calves is incorrect. The nurse should recognize that massage is contraindicated in a client who is at risk for DVT development. Massage can cause small thrombi to break loose from the vein wall and move through the circulatory system, potentially resulting in complications such as a stroke, myocardial infarction, or pulmonary embolism. 40. A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client’s risk of skin breakdown? (Select all that apply.) INCORRECT 1) Massage erythematous bony prominences. INCORRECT 2) Implement turning schedule every 4 hr. 3) Use pillows to keep heels off the bed surface. INCORRECT 4) Keep environmental humidity less than 30%. 5) Minimize skin exposure to moisture. Answer Rationale: Massage erythematous bony prominences is incorrect. The nurse should avoid massaging erythematous bony prominences, which would cause further skin breakdown. Implement turning schedule every 4 hr is incorrect. The nurse should implement a turning schedule to prevent skin breakdown. This includes turning the client every 2 hr while in bed and repositioning hourly if the client is up in a chair. Use pillows to keep heels off the bed surface is correct. The nurse should pad all bony prominences and use devices such as pillows to keep the heels off the bed surface and prevent skin breakdown. Keep environmental humidity less than 30% is incorrect. The nurse should manage humidity in the client’s room and keep the humidity above 40%. Humidity less than 40% is drying to the skin and increases the risk of skin breakdown. Minimize skin exposure to moisture is correct. The nurse should include actions to minimize exposure of the skin to moisture from sweating, wound drainage or incontinence as this causes maceration of the skin which leads to skin breakdown. 41. A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.) 1) Provide a suction setup at the bedside. 2) Elevate the side rails when in bed. INCORRECT 3) Place a bite stick at the bedside. 4) Keep an oxygen setup at the bedside. INCORRECT 5) Furnish restraints at the bedside. Answer Rationale: Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning following the seizure to prevent aspiration.Elevate the side rails when in bed. The nurse should elevate the rails of the bed to prevent a fall in the event the client has a seizure. Additional measures may be taken such as padding the side rails to prevent injury from hitting the side rails during seizure activity.Place a bite stick at the bedside is incorrect. The nurse should recognize that attempting to insert anything into the mouth of a client who is having a seizure can result in injury to the client or the nurse.Keep an oxygen setup at the bedside is correct. The nurse should keep an oxygen setup at the bedside to administer oxygen during any seizure activity if this can be done safely. The nurse should recognize that, during tonic seizure activity, respirations cease and the client becomes cyanotic.Furnish restraints at the bedside is incorrect. The nurse should recognize that the client who is experiencing seizure activity should not be restrained, as this can lead to injury to the client, such as fractures. 42. A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.) 1) Rest INCORRECT 2) Movement INCORRECT 3) Heat application 4) Compression 5) Elevation Answer Rationale: Rest is correct. Rest helps limit the movement of the extremity and prevents further injury.Movement is incorrect. Movement of the sprained area can cause pain and further injury.Heat application is incorrect. Ice application causes vasoconstriction and reduces nerve impulse transmission, which provides pain relief and reduces swelling and muscle spasms.Compression is correct. Compression reduces edema, helping to relieve pain.Elevation is correct. Elevation reduces edema, helping to relieve pain. 43. A nurse is reinforcing teaching with a client who has a new diagnosis of testicular cancer. Which of the following statements should the nurse include in in the teaching? (Select all that apply.) 1) Close male relatives are at increased risk for the disease. 2) It typically occurs between ages 15 to 40. INCORRECT 3) It occurs in both testicles equally. INCORRECT 4) Impotence usually occurs after an orchiectomy. INCORRECT 5) An early sign is scrotal warmth and redness. Answer Rationale: Close male relatives are at increased risk for the disease is correct. Testicular cancers are more common in clients with a family history of testicular cancer. Therefore, close male relatives are at increased risk.It typically occurs between ages 15 to 40 is correct. Testicular cancer occurs in the productive years and has significant economic, social, and psychological impact on the client and his family.It occurs in both testicles equally is incorrect. Testicular cancer is rarely bilateral.Impotence usually occurs after an orchiectomy is incorrect. Erectile dysfunction is a rare complication following orchiectomy.An early sign is scrotal warmth and redness is incorrect. Painless scrotal swelling, backache, and weight loss are early signs. 44. A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promoting wound healing? (Select all that apply.) 1) Vitamin A INCORRECT 2) Vitamin B12 3) Vitamin C INCORRECT 4) Vitamin D INCORRECT 5) Vitamin E Answer Rationale: Vitamin A is correct. The nurse should reinforce the importance of including vitamin A in the diet to promote wound healing. It promotes tissue synthesis, wound healing, and immune function. Foods containing vitamin A include sweet potatoes, carrots, spinach, and cantaloupe. Vitamin B12 is incorrect. The nurse should recognize that vitamin B12 assists in the development of red blood cells and maintenance of nerve function but has no specific role in wound healing. Vitamin C is correct. The nurse should include the importance of vitamin C in wound healing. It plays a role in capillary formation, tissue synthesis, and wound healing. Foods high in vitamin C include oranges, kiwi, cantaloupe, strawberries, and broccoli. Vitamin D is incorrect. Vitamin D functions in maintaining serum levels of calcium and phosphorus, but has no specific role in wound healing. Vitamin E is incorrect. Vitamin E functions as an antioxidant to protect from cell proliferation, but has no specific role in wound healing. 45. A nurse is reviewing home medications of a male client who has a new prescription for warfarin. Which of the following of the client's herbal medications should the nurse identify as being contraindicated to warfarin? (Select all that apply.) 1) Saw palmetto INCORRECT 2) Echinacea 3) Glucosamine INCORRECT 4) Flaxseed 5) Gingko biloba Answer Rationale: Saw palmetto is correct. The nurse should identify saw palmetto as an herbal supplement that is used to improve urinary stream in some men who have benign prostatic hypertrophy (BPH). It has antiplatelet effects and is contraindicated for use along with warfarin.Echinacea is incorrect. The nurse should recognize that echinacea is used to stimulate immune function, suppress inflammation and has been shown to shorten the duration of viral infections, such as influenza and the common cold. It does not interact with warfarin.Glucosamine is correct. The nurse should recognize that glucosamine is used to reduce the pain associated with osteoarthritis and may increase joint mobility. It may increase the risk of bleeding and should not be used in conjunction with warfarin.Flaxseed is incorrect. The nurse should identify flaxseed use as aiding in the reduction of serum cholesterol and for the treatment of constipation. It does not interact with warfarin.Gingko biloba is correct. The nurse should recognize that ginkgo biloba has been shown to improve blood circulation, which might help the brain, eyes, ears, and legs function better. It also has anticoagulant effects, so it should not be used in conjunction with warfarin. 46. A nurse is reinforcing teaching with a group of clients about common findings that can indicate cancer. The nurse should instruct the clients to monitor for and report which of the following findings? (Select all that apply.) 1) A nonhealing sore INCORRECT 2) Unintended weight gain 3) Change in bowel pattern 4) Unilateral calf tenderness 5) Nagging cough Answer Rationale: A nonhealing sore is correct. A client who has cancer might exhibit a nonhealing sore. Unintended weight gain is incorrect. The nurse should instruct the clients that unintended weight loss can indicate cancer. Change in bowel pattern is correct. A client who has cancer might exhibit a change in bowel pattern. Unilateral calf tenderness is incorrect. A client who has unilateral calf tenderness can have a venous thromboembolism. Nagging cough is correct. A client who has cancer might exhibit a nagging cough. 47. A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.) 1) Use an alcohol-based hand cleaner unless hands are visibly soiled. 2) Remind the client to cover her mouth with a tissue when coughing. 3) Determine whether the client lives alone or with others. INCORRECT 4) Place the client in a room with positive airflow. INCORRECT 5) Instruct the client about taking antifungal medications. Answer Rationale: Use an alcohol-based hand cleaner unless hands are visibly soiled is correct. The nurse should plan to use an alcohol-based hand cleaner after client care tasks when caring for a client who has TB. The nurse should wash her hands with soap and water after performing care for any client in which the hands become visibly contaminated. Remind the client to cover her mouth with a tissue when coughing is correct. The nurse should remind the client to cover her mouth with a tissue when coughing to minimize contamination of the air in the client’s room. Determine whether the client lives alone or with others is correct. The nurse should determine any close contacts the client has and recommend that those individuals undergo Mantoux testing. Place the client in a room with positive airflow is incorrect. The nurse should plan to place the client in a room with negative airflow to prevent air contaminated with TB from entering the hallways. Instruct the client about taking antifungal medications is incorrect. The nurse should instruct the client about taking antibiotic medications to treat TB. 48. A nurse is collecting data from a client. The provider suspects the client may have syndrome of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse should ask for additional information about which of the following conditions? (Select all that apply.) INCORRECT 1) Osteoarthritis 2) Lung cancer INCORRECT 3) Liver cirrhosis INCORRECT 4) Dyspepsia 5) Seizures Answer Rationale: Osteoarthritis is incorrect. It is not necessary for the nurse to ask about osteoarthritis when obtaining a medical history because it does not impact the secretion of antidiuretic hormone. Lung cancer is correct. The nurse should ask the client about lung cancer when obtaining a medical history because some of the treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This results in the body retaining water and can cause SIADH. Liver cirrhosis is incorrect. It is not necessary for the nurse to ask about liver cirrhosis when obtaining a medical history because it does not impact the secretion of antidiuretic hormone. Dyspepsia is incorrect. It is not necessary for the nurse to ask about dyspepsia when obtaining a medical history because it does not impact the secretion of antidiuretic hormone. Seizures is correct. The nurse should ask the client about seizures when obtaining a medical history. Due to increase fluid volume, the excess results in hyponatremia which can cause confusion. 49. A nurse is reinforcing teaching with a client about risk factors for osteoarthritis. Which of the following risk factors should the nurse identify as contributing to this diagnosis? (Select all that apply.) INCORRECT 1) Bacteria INCORRECT 2) Diuretics 3) Aging 4) Obesity INCORRECT 5) Smoking Answer Rationale: Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which does not cause irreversible damage to joints. Infection is not a risk factor for osteoarthritis. Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for osteoarthritis. Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the body’s weight over time. Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body’s weight over time. Smoking is incorrect. Smoking is a risk factor for osteoporosis, but not for osteoarthritis. 50. A nurse is assisting with the care of an older adult client who is scheduled for surgery. The nurse should identify that the client is at risk for which of the following? (Select all that apply.) 1) A decrease in kidney function 2) A decrease in the skin elasticity INCORRECT 3) A decrease in medication efficacy INCORRECT 4) An increase in metabolism INCORRECT 5) An increase in cardiac output Answer Rationale: A decrease in kidney function is correct. This is a surgical risk the nurse should be aware of. Older adults have a risk for complications that is three times higher than that of younger adult. A decrease in the skin elasticity is correct. Older adults have a decrease in skin elasticity. This is a surgical risk the nurse should be aware of. A decrease in medication efficacy is incorrect. Older adults have an increase in medication efficacy. A decline in cardiac, renal, or liver function can delay the metabolism or excretion of medications. An increase in metabolism is incorrect. Older adults have a decrease in metabolism. A decline in cardiac, renal, or liver function can delay the metabolism or excretion of medications. An increase in cardiac output is incorrect. Older adults have a decreased cardiac output. A decline in cardiac output can delay the metabolism or excretion of medications. 51. A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.) INCORRECT 1) Client's ability to pay for the consented surgical procedure INCORRECT 2) Client's ability to read the consent form 3) Disclosure of the treatment is provided 4) Client understands the surgical procedure 5) Voluntary consent is given Answer Rationale: Client's ability to pay for the consented surgical procedure is incorrect. The client's ability to pay for the consented surgical procedure is not related to informed consent. Client's ability to read the consent form is incorrect. It is not necessary for the client to personally read the consent form. Disclosure of the treatment is provided is correct. The client should be informed of treatment that is to be provided as well as the risks involved. Informed consent protects the client, the provider, the institution, and the employees. Client understands the surgical procedure is correct. The client should understand the surgical procedure as well as the risks. Informed consent protects the client, the provider, the institution, and the employees. Voluntary consent is given is correct. The client should give voluntary consent for the procedure without influence. Informed consent protects the client, provider, the institution, and the employees. 52. A nurse is reinforcing teaching with a female client about risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.) 1) Sedentary lifestyle INCORRECT 2) Obesity 3) Aging 4) Caffeine intake 5) Smoking Answer Rationale: Sedentary lifestyle is correct. Immobility depletes bone. Obesity is incorrect. Obesity is a risk factor for developing osteoarthritis. Aging is correct. Women lose bone density due to estrogen depletion after menopause. Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine. Smoking is correct. Smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking. 53. A nurse is reinforcing teaching about ergonomic principles with a group of assistive personnel. Which of the following strategies should the nurse include in the teaching? (Select all that apply.) 1) Tighten the abdominal muscles when lifting objects. INCORRECT 2) Limit lifting to no more than 22.68 kg (50 lb) without assistance. 3) Flex knees and hips periodically when standing for a period of time. INCORRECT 4) Maintain straight knees when picking items up from the floor. 5) Enlarge the distance between the front foot and the back foot when pulling a client towards you. Answer Rationale: Tighten the abdominal muscles when lifting objects is correct. The abdominal muscles can provide balance and support to the back when lifting if they are tightened and the pelvis is tucked under. Limit lifting to no more than 22.68 kg (50 lb) without assistance is incorrect. The nurse should emphasize that no more than 15.88 kg (35 lb) should be lifted without assistance. An amount greater than 35 lb increases the risk of musculoskeletal injury. Flex knees and hips periodically when standing for a period of time is correct. The nurse should emphasize that occasionally flexing the knees and hips when standing for long periods of time helps relieve the strain on the lower back and prevents back injuries. Maintain straight knees when picking items up from the floor is incorrect. The nurse should emphasize that bending at the knees when lifting an object off the floor helps maintain the center of gravity and allows the stronger muscles of the thighs to do the lifting. Acute flexion of the back while keeping the knees straight should be avoided as this can result in musculoskeletal injury. Enlarge the distance between the front foot and the back foot when pulling a client towards you is correct. The nurse should emphasize that when pulling or pushing an object, increasing the base of support by widening the stance increases balance and limits the risk of musculoskeletal injury. 54. A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply.) 1) Cool skin 2) Absence of pulse INCORRECT 3) Pain relieved by narcotics INCORRECT 4) Capillary refill 1 second 5) Altered sensation of the toes Answer Rationale: Cool skin is correct. The nurse should identify pallor as a possible manifestation of compartment syndrome. Absence of pulse is correct. The nurse should identify pulselessness as a possible manifestation of compartment syndrome. Pain that is relieved by narcotics is incorrect. The nurse should expect pain that is beyond the expected level for the client’s condition and is unrelieved by narcotics as a possible manifestation of compartment syndrome. Capillary refill 1 second is incorrect. The nurse should expect a client who has compartment syndrome to have delayed capillary refill (2 seconds or greater). Altered sensation of the toes is correct. The nurse should identify paresthesias as a possible manifestation of compartment syndrome. 55. A nurse is assisting with a presentation at a community center about knee disorders and injuries. The nurse should include which of the following as risk factors for developing osteoarthritis? (Select all that apply.) 1) Obesity 2) Family history of osteoarthritis INCORRECT 3) Calcium deficiency 4) Aging 5) Regular, strenuous exercise Answer Rationale: Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time. Family history of osteoarthritis is correct. A client can have a genetic predisposition for developing osteoarthritis. Calcium deficiency is incorrect. Too little calcium leads to osteoporosis, rather than osteoarthritis. Aging is correct.Aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. Regular, strenuous exercise is correct. Strenuous exercise and repetitive motion can result in osteoarthritis. 56. A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.) INCORRECT 1) Apply heat to the client’s ankle. INCORRECT 2) Encourage range of motion of the client’s foot. INCORRECT 3) Check the client’s toes for color, temperature, and sensation. 4) Apply a compression bandage to the client’s ankle. 5) Elevate the client’s foot. Answer Rationale: Apply heat to the client’s ankle is incorrect. The nurse should apply Ice to reduce swelling and pain. Encourage range of motion of the client’s foot is incorrect. The client should avoid any movement that could cause further pain and tissue injury. Check the client’s toes for color, temperature, and sensation is correct. The nurse should check the circulation and sensation of the client’s foot to evaluate for nerve or circulatory impairment. Apply a compression bandage is correct. Wrapping an elastic bandage around the ankle can reduce edema and pain. Elevate the foot is correct. Elevation can reduce edema and pain. 57.A nurse is working with community members to prepare for an external disaster. The nurse is assisting the community members to compile a list of basic supplies needed in the case of a disaster. Which of the following supplies should the nurse instruct the community members to include? (Select all that apply.) INCORRECT 1) Three quarts of water per person 2) Clean clothing 3) Personal identification 4) Matches INCORRECT 5) Family possessions Answer Rationale: Three quarts of water per person is incorrect. One gallon or 4 quarts of water per person per day is the recommended amount of water for basic supplies for personal preparedness. A three day supply minimum is recommended. Clean clothing is correct. Clean clothing is recommended to include in basic supplies for personal preparedness. Personal identification is correct. Personal identification is recommended to include in basic supplies for personal preparedness. Matches is correct. Matches are recommended to include in basic supplies for personal preparedness. Family personal possessions are incorrect. This is not a part of basic supplies that will assist in the case of a disaster event. 58. A nurse is caring for a client who has multiple injuries following a motor-vehicle crash. The nurse should collect data concerning which of the following areas when using primary survey triage? (Select all that apply.) 1) Airway 2) Circulation 3) Disability 4) Exposure INCORRECT 5) Urinary output Answer Rationale: Airway is correct. Airway is part of the ABCDE mnemonic that is used to guide a primary survey of a client who has traumatic injuries. Circulation is correct. Circulation is part of the ABCDE mnemonic that is used to guide a primary survey of a client who has traumatic injuries. Disability is correct. Disability is part of the ABCDE mnemonic that is used to guide a primary survey of a client who has traumatic injuries. Exposure is correct. Exposure is part of the ABCDE mnemonic that is used to guide a primary survey of a client who has traumatic injuries. Urinary output is incorrect. Urinary output is not part of the ABCDE mnemonic that is used to guide a primary survey of a client who has traumatic injuries. 59. A nurse at a provider’s office is reviewing information about management of osteoarthritis with a client. Which of the following interventions should the nurse recommend? (Select all that apply.) 1) Weight management 2) Aerobic exercise 3) Massage therapy INCORRECT 4) Cold compresses 5) Isometric exercise Answer Rationale: Weight management is correct. The client should maintain appropriate body weight to reduce strain on the joints and helps relieve pain. Aerobic exercise is correct. The nurse should encourage the client to engage in regular low-impact aerobic exercise. Massage therapy is correct. Massage therapy increases circulation, relieves pain, and promotes relaxation. Cold compresses is incorrect. The nurse should encourage the client to use moist heat to provide pain relief and reduce muscle spasms (warm packs, tub baths, showers, and heated gloves or wax dips). Isometric exercise is correct. The nurse should recommend isometric exercise to maintain mobility and prevent joint contractures. 60. A nurse is assisting with the care of a client who has hypertension and chronic kidney disease. The client is scheduled for hemodialysis. Which of the following actions should the nurse plan to take while caring for this client? (Select all that apply.) 1) Document vital signs. 2) Obtain the client's weight. INCORRECT 3) Verify the glomerular filtration rate. INCORRECT 4) Administer a sedative to the client. 5) Check the graft site for a palpable thrill. Answer Rationale: Document vital signs is correct. The client's vital signs should be taken and documented prior to dialysis for baseline data. The client's blood pressure, in particular, should be monitored prior to, during, and after dialysis due to the potential for hypotension during and after the treatment. If the blood pressure drops too low, an infusion of intravenous normal saline may be required to replace fluid volume and restore the blood pressure. Obtain the client's weight is correct. Hemodialysis shunts the client's blood from the body through a dialyzer and back into the client's circulation. During hemodialysis, the blood is passed through the dialysis machine to remove waste products and excess fluid. The amount of fluid to be removed is determined by the client's weight immediately prior to dialysis. The client's dry weight, which is determined by the provider, is subtracted from the weight immediately prior to the start of dialysis. For example, if the dry weight is 70 kg (154.32 lb) and the current weight is 72 kg (158.73 lb), the dialysis machine is programmed to remove 2 kg (4.4 lb), or 2 L (0.5 gal) of fluid. Verify the glomerular filtration rate is incorrect. End-stage kidney disease (ESKD) is a progressive, irreversible kidney disease. End-stage kidney disease, also known as end-stage renal failure (ESRD), exists when 90% of the functioning nephrons have been destroyed and are no longer able to maintain fluid, electrolyte, or acid-base homeostasis. This means the kidneys are no longer able to sustain life, and the client will die if dialysis is not initiated. The client's glomerular filtration rate (GFR) is used to determine the severity of kidney damage. The GFR is expected to be greater than 90 mL/min. Chronic kidney disease (CKD) is comprised of five stages: Stage 1, minimal kidney damage with normal GFR; Stage 2, mild kidney damage with mildly decreased GFR; Stage 3, moderate kidney damage with a moderate decrease in GFR; Stage 4, severe kidney damage with a severe decrease in GFR; and Stage 5, kidney failure and end-stage kidney disease with little or no glomerular filtration and renal replacement therapy required. Glomerular filtration rate is an indicator of renal function and is checked to evaluate how well the kidneys are working. Because ESKD is irreversible, it is not necessary to check the GFR prior to dialysis because the GFR level in these clients is elevated and will remain that way unless a renal transplantation is performed. Administer a sedative is incorrect. The client is awake during hemodialysis and is a painless procedure for the client. Therefore, a sedative is not needed. Check the graft site for a palpable thrill is correct. Hemodialysis requires access to the client's blood by way of a graft, arteriovenous (AV) fistula, or central venous access device. The nurse should check patency of the access site (presence of bruit, palpable thrill, distal pulses, and circulation). This ensures vascular flow and proper functioning of the graft prior to the dialysis procedure. If a thrill is not found, this can indicate the graft has clotted and hemodialysis will not be possible. This would need to be reported to the provider. Measures to protect the graft include avoiding taking blood pressure, administering injections, performing venipuncture, or inserting IV lines on an extremity with an access site. 61. A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) 1) "I must stop smoking." INCORRECT 2) "I should lower my HDL cholesterol level." INCORRECT 3) "I will stop consuming alcohol." 4) "I need to monitor my weight." 5) "I am limiting my intake of fast foods." Answer Rationale: "I must stop smoking." is correct. Smoking places the client at three to four times higher risk for developing coronary disease, but the benefits of stopping smoking occur almost immediately. "I should lower my HDL cholesterol level." is incorrect. The nurse should remind the client that this type of cholesterol is beneficial to removing bad cholesterol from the body. "I will stop consuming alcohol." is incorrect. The client should limit alcohol consumption to 2 drinks per day for men and 1 drink per day for women. "I need to monitor my weight." is correct. Obesity, or an increase in weight, is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. "I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling. 62. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.) INCORRECT 1) Add the amount of bladder irrigation to the total output. 2) Use sterile technique when preparing the irrigation solution. 3) Make sure the drainage tubing is patent and without obstruction. INCORRECT 4) Contact the surgeon if the client reports a continual need to void. 5) Notify the surgeon if the urine is bright red or has large clots. Answer Rationale: Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract the amount of bladder irrigation solution from the total urine output amount. For example, if the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, the nurse should subtract 1,000 from 2,500 and record 1,500 mL as the total urine output. Use sterile technique when preparing the irrigation solution is correct. Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. The nurse should observe these clients closely for manifestations of infection, such as fever and elevated WBC counts. Make sure the drainage tubing is patent and without obstruction is correct. For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter system. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury. Contact the surgeon if the client reports a continual need to void is incorrect. The post-TURP catheter is large; the surgeon pulls it taut and secures it to the client’s leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client probably will feel a continual need to void. The nurse should tell the client to expect this urge to void. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and can initiate bleeding. Notify the surgeon if the urine is bright red or has large clots is correct. It is important to record the type and amount of irrigation solution and the character of the drainage. The nurse should expect to see a few small blood clots, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding. The nurse should report this to the surgeon immediately and monitor the client’s Hgb and Hct to help determine the degree of blood loss. 63. A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) 1) "I must stop smoking." INCORRECT 2) "I should lower my HDL cholesterol level." INCORRECT 3) "I will stop consuming alcohol." 4) "I need to monitor my weight." 5) "I am limiting my intake of fast foods." Answer Rationale: "I must stop smoking." is correct. Smoking places the client at three to four times higher risk for developing coronary disease, but the benefits of stopping smoking occur almost immediately. "I should lower my HDL cholesterol level." is incorrect. The nurse should remind the client that this type of cholesterol is beneficial to removing bad cholesterol from the body. "I will stop consuming alcohol." is incorrect. The client should limit alcohol consumption to 2 drinks per day for men and 1 drink per day for women. "I need to monitor my weight." is correct. Obesity, or an increase in weight, is a significant factor in developing coronary artery disease. Weight management is vital to decreasing the risk of coronary artery disease. "I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling. 64. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.) INCORRECT 1) Add the amount of bladder irrigation to the total output. 2) Use sterile technique when preparing the irrigation solution. 3) Make sure the drainage tubing is patent and without obstruction. INCORRECT 4) Contact the surgeon if the client reports a continual need to void. 5) Notify the surgeon if the urine is bright red or has large clots. Answer Rationale: Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract the amount of bladder irrigation solution from the total urine output amount. For example, if the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, the nurse should subtract 1,000 from 2,500 and record 1,500 mL as the total urine output. Use sterile technique when preparing the irrigation solution is correct. Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. The nurse should observe these clients closely for manifestations of infection, such as fever and elevated WBC counts. Make sure the drainage tubing is patent and without obstruction is correct. For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter system. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury. Contact the surgeon if the client reports a continual need to void is incorrect. The post-TURP catheter is large; the surgeon pulls it taut and secures it to the client’s leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client probably will feel a continual need to void. The nurse should tell the client to expect this urge to void. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and can initiate bleeding. Notify the surgeon if the urine is bright red or has large clots is correct. It is important to record the type and amount of irrigation solution and the character of the drainage. The nurse should expect to see a few small blood clots, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding. The nurse should report this to the surgeon immediately and monitor the client’s Hgb and Hct to help determine the degree of blood loss. 65. A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) INCORRECT 1) Instruct the client to cough and deep breathe every 4 hr. 2) Have the client sit at the bedside prior to getting up. INCORRECT 3) Remove compression stockings once per day. 4) Provide pain medications around the clock for the first 48 hr. INCORRECT 5) Encourage intake of foods high in carbohydrates. Answer Rationale: Instruct the client to cough and deep breathe every 4 hr is incorrect. The nurse should encourage the client to cough and deep breathe every 1 to 2 hr while awake to decrease the risk of atelectasis and pneumonia. Have the client sit at the bedside prior to getting up is correct. Sitting at the bedside prior to rising reduces the risk of the client experiencing orthostatic hypotension. Remove compression stockings once per day is incorrect. Compression stockings should be removed at least once per shift in order to perform a through skin assessment. Provide pain medications around the clock for the first 48 hr is correct. Relieving pain allows the client to better participate in postoperative therapies and minimize risks associated with surgery. Encourage intake of foods high in carbohydrates is incorrect. Once the client is able to tolerate oral intake, the nurse should encourage consumption of foods high in protein and vitamin C to promote wound healing. 66. A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following interventions should the nurse include? (Select all that apply.) 1) Assist the client to develop an individualized meal plan. INCORRECT 2) Give the client an extra dose of insulin for a blood glucose level of 50 mg/dL. INCORRECT 3) Instruct the client to soak his feet daily. 4) Offer the client 240 mL (8 oz) of skim milk if the client’s skin becomes cool and clammy. 5) Check the client’s blood glucose level before meals and bedtime. Answer Rationale: Assist the client to develop an individualized meal plan is correct. A client who has a new diagnosis of type 2 diabetes mellitus will need assistance to develop a meal plan that will help him achieve his weight goals, maintain his lifestyle, and meet his food preferences. Give the client an extra dose of insulin for a blood glucose level of 50 mg/dL is incorrect. A blood glucose level of 50 mg/dL is below the expected reference range. Giving an extra dose of insulin can further lower the client’s blood glucose level. Instruct the client to soak his feet daily is incorrect. Soaking the feet daily can cause skin impairment and lead to cracking of the skin. This can increase the client’s risk for infection. The client should wash his feet in warm water and mild soap and dry them thoroughly before putting on socks. Offer the client 8 oz of skim milk if the client’s skin becomes cool and clammy is correct. Cool, clammy skin, pallor, irritability, and shakiness can indicate the client’s blood glucose is below the expected reference range and that the client is having hypoglycemia. The nurse should offer the client a snack of 15 to 20 g of carbohydrate, such as 8 oz of skim milk, 1 small box of raisins, or 4 oz of juice. Check the client’s blood glucose level before meals and bedtime is correct. The nurse should check the client’s blood glucose level at least before each meal and at bedtime to monitor glucose control and identify the need for medication. 67. A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.) 1) Provide oral fluids 2) Monitor for nausea INCORRECT 3) Maintain fetal position 4) Check level of consciousness 5) Check sensation in the toes Answer Rationale: Provide oral fluids is correct. The nurse should encourage fluid intake to replace fluid loss during the procedure. Monitor for nausea is correct. The nurse should monitor nausea as a possible manifestation of increased intracranial pressure. Additional findings to report include headache or drainage or redness at the puncture site. Maintain fetal position is incorrect. Following a lumbar puncture (LP), the nurse should keep the client flat and still for 4 to 8 hr to decrease leakage of cerebral spinal fluid from the LP site. The fetal position is used during the LP procedure to open the spaces in the vertebrae. Check level of consciousness is correct. The nurse should monitor for a change in the client’s level of consciousness as a possible manifestation of increased intracranial pressure. The nurse should also monitor for photophobia. Check sensation in the toes is correct. A lumbar puncture could cause injury to the spinal cord; therefore, the nurse should monitor the client’s neurological status in both lower extremities. 68. A nurse is caring for a client who has a closed wound drainage system connected to a portable bulb suction device. Which of the following actions should the nurse take to care for the drain? (Select all that apply.) INCORRECT 1) Allow the drain fill completely before emptying. INCORRECT 2) Flush the drainage tube with sterile water each shift. 3) Wipe the top of the drainage port with an alcohol swab after emptying. INCORRECT 4) Milk the drainage port to promote emptying.> 5) Squeeze the suction bulb while inserting the plug into the drainage port. Answer Rationale: Allow the drain fill completely before emptying is incorrect. The nurse is responsible for maintaining negative pressure suction on the drainage device and should not allow the bulb to fill completely as it would no longer provide wound suction. The nurse should empty the drain at least every shift and as needed. Flush the drainage tube with sterile water each shift is incorrect. The nurse should not insert anything into the drainage tube in order to protect the sterility of the device. Wipe the top of the drainage port with an alcohol swab after emptying is correct. The nurse should wipe the opening of the port with an alcohol swab to remove fluid and contaminants prior to reactivating and closing the device. This action promotes sterility of the device. Milk the drainage port to promote emptying is incorrect. The nurse should avoid touching the drainage port to promote asepsis of the drainage system. Squeeze the suction bulb while inserting the plug into the drainage port is correct. The nurse should squeeze the bulb and maintain it in that position while inserting the drainage plug to reactivate negative pressure and ensure the drainage device continues to evacuate fluid from the drain. 69. A nurse working in an assisted living facility has been made aware that a chemical disaster has occurred within the community and is a threat to the facility. Which of the following actions should the nurse take? (select all that apply) INCORRECT 1) Evacuate the facility of all residents and staff. 2) Place wet towels under the doors. 3) Close the doors and windows of each resident's apartment. INCORRECT 4) Open the fireplace dampers in each resident's apartment. 5) Turn off fans and heaters. Answer Rationale: Evacuate the facility of all residents and staff is incorrect. During a chemical disaster, the nurse should ensure that all residents and staff members stay inside until told it is safe to go outside. Place wet towels under the doors is correct. The nurse should place wet towels under the doors to prevent the chemical from traveling into residents’ rooms. Close the doors and windows of each resident's apartment is correct. The nurse should closed all of the doors and windows of each client's apartments to prevent the chemical from coming into the building. Open the fireplace dampers in each resident's apartment is incorrect.The nurse should close all fireplace dampers. This prevents the chemical from coming in from the outside. Turn off fans and heaters is correct. This prevents the circulation of air, and possibly chemicals, in from the outside and contaminating the air inside the building. 70. A nurse is reinforcing breast self- examination (BSE) teaching with a client who is menopausal. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.) 1) "I can stand in the shower to perform the examination." INCORRECT 2) "I will use my fingertips to check my breasts." 3) "It is important to press my breasts firmly to detect any lumps." 4) "Since I no longer have periods, I can do the exam at any time of the month." 5) "I will make sure to feel for changes in my underarm area." Answer Rationale: "I can stand in the shower to perform the examination." is correct. A client can perform a BSE while in a lying position, or when bathing or showering."I will use my fingertips to check my breasts." is incorrect. The client should be instructed to use her fingerpads since they are more sensitive than fingertips."It is important to press my breasts firmly to detect any lumps." is correct. Women should press firmly on the breasts to detect changes in underlying tissues. The nurse should demonstrate the proper amount of pressure and the correct positioning of the hands."Since I no longer have periods, I can do the exam at any time of the month." is correct. Women who no longer have the monthly hormonal influences of menstruation can perform an examination at any time. Inform the client that It is best to select a specific date each month for her BSE."I will make sure to feel for changes in my underarm area." is correct. It is important to check the area between the breast tissue and the underarm as well as the underarm itself for any changes. Lymph nodes located in this area are assessed for inflammation, tenderness, and firmness. 71. A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of coronary heart disease. Which of the following actions should the nurse take? (Select all that apply.) INCORRECT 1) Keep the client NPO after midnight. 2) Inspect the electrode pads. 3) Use alcohol to wipe the skin before placing the electrodes. 4) Instruct the client to breath normally. INCORRECT 5) Administer an analgesic prior to the procedure. Answer Rationale: Keep the client NPO after midnight is incorrect. The client will not receive anesthesia for to the test so he does not need to follow a food or fluid restriction prior to the test. Inspect the electrode pads is correct. The nurse should inspect the electrode pads to check that the gel is present because the gel is necessary to promote electrical conduction between the skin and the electrodes. Use alcohol to wipe the skin before placing the electrodes is correct. The nurse should wipe the skin where she will place the electrodes to ensure the skin is free of oils and other matter. Instruct the client not to talk is correct. The nurse should instruct the client to lie quietly, not talk, or move to prevent the recording of artifact. Administer an analgesic prior to the procedure is incorrect. The client does not need to receive an analgesic prior to the test because the test is noninvasive and does cause any discomfort. 72. A nurse is reinforcing preoperative teaching about breathing exercises with a client. Which of the following instructions should the nurse include? (Select all that apply.) INCORRECT 1) Make the chest and shoulders move when inhaling. 2) Exhale through pursed lips. INCORRECT 3) Perform deep breathing every 2 hr around the clock. 4) Sit in an upright position before beginning coughing exercises. INCORRECT 5) Take a deep breath between each attempt to cough. Answer Rationale: Make the chest and shoulders move when taking inhaling is incorrect. The nurse should instruct the client to use abdominal muscles for deep breathing, and to avoid using the chest and shoulders while inhaling. Exhale through pursed lips is correct. The nurse should have the client exhale as if blowing out a candle to promote slow release of air from the lungs. Perform deep breathing every 2 hr around the clock is incorrect. The nurse should instruct the client to perform deep breathing exercises every hour while awake to prevent atelectasis. Sit in an upright position before beginning coughing exercises is correct. The nurse should instruct the client to sit in a semi-Fowler’s or sitting position to promote expansion of the diaphragm and thoracic region. Take a deep breath between each attempt to cough is incorrect. The nurse should instruct the client to take two deep breaths, then inhale deeply. After holding the breath several seconds, the clients should cough two to three times consecutively to promote mucus expulsion from the lungs. 73. A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take? (Select all that apply.) 1) Monitor peripheral pulses in the affected extremity. INCORRECT 2) Position weights against the foot of the bed. INCORRECT 3) Adjust the prescribed weights every shift. 4) Examine the skin under the traction splint. 5) Assess the temperature of the affected extremity. Answer Rationale: Monitor peripheral pulses in the affected extremity is correct. The fracture and the traction device can compromise circulation to the extremity, so checking peripheral pulses is necessary to evaluate tissue perfusion. Position weights against the foot of the bed is incorrect. The weights should hang freely away from the foot of bed to promote proper traction and healing. Adjust the prescribed weights every shift is incorrect. Once the weights are in place, the nurse should not adjust or remove them unless the provider prescribes changes. Examine the skin under the traction splint is correct. The nurse should monitor the client’s skin integrity because immobility can reduce sensation in the extremity. The client might not feel any breakdown in the skin. Assess the temperature of the affected extremity is correct. The fracture and the traction device can compromise circulation to the extremity, so checking the temperature is necessary to evaluate tissue perfusion. [Show More]

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