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review missed questions

"You sound really discouraged today."

Sharing an observation with the client conveys awareness of the client's feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.

roll the vial gently between the palms.

Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

Placing the client in a side-lying position

An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene; doing so allows fluid to drain from the mouth, preventing aspiration. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn't be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler's position would increase the risk of aspiration.

"Remember to hold the cane with the hand on the opposite side of your weak leg."

The nurse should remind the client to hold the cane with the hand on the opposite side of the weak leg. Telling the client that the cane is temporary offers false reassurance. Safe cane walking requires the client to hold the cane on the side opposite the disability.

Assisting the client with deep-breathing exercises

Deep-breathing exercises are beneficial to promoting rest as they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. While sedatives may be used occasionally for assistance with rest, regular use isn't advised because dependence may develop.

Lactic acidosis

The nurse should monitor the client for signs of lactic acidosis, a life- threatening adverse reaction associated with metformin. Nausea, vomiting, and megaloblastic anemia are adverse reactions associated with metformin, but they aren't considered life-threatening.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful? Select all that apply.
Recommending community resources for adult day care and respite care

• Encouraging the spouse to talk about the difficulties involved in caring for a loved one
• Asking whether friends or church members can help with errands or provide short periods of relief
Explanation: Many community services exist for Alzheimer's clients and their families. Encouraging use of these resources may make it possible to keep the client at home and to alleviate the spouse's exhaustion. The nurse can also support the caregiver by urging her to talk about the difficulties she's facing in caring for her spouse. Friends and church members may be able to help provide care to the client, allowing the caregiver time for rest, exercise, or an enjoyable activity. Arranging a family meeting to tell the children to participate more would probably be ineffective and might evoke anger or guilt. Counseling might be helpful, but it wouldn't alleviate the caregiver's physical exhaustion or address the client's immediate needs. A long-term care facility isn't an option until the family is ready to make that decision.

Restlessness

Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the client restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool, clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

The tongue

In many cases, the muscles controlling the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw- thrust maneuver must be performed. A foreign object, saliva or mucus, and edema are less common sources of airway obstruction in an unconscious adult.

The nurse-client relationship

Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.

Notify the nursing supervisor and approach the individual.

Approaching the person and requesting the client's medical record isn't sufficient considering the confidential health care information. Notifying the nursing supervisor, then approaching the individual before informing the client provides the most appropriate approach to this breech of client confidentiality. Contacting security might not be warranted unless the nurse learns the reason the unauthorized individual was reading the client's chart. The nurse should also document the incident according to facility policy.

Ineffective peripheral tissue perfusion related to venous congestion

Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Option 1 is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option 2 is inappropriate because no evidence suggests that this client has a excessive fluid volume. Option 3 may be warranted but is secondary to ineffective tissue perfusion.

Evaluation

During the evaluation step of the nursing process, the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met, the nurse reexamines the data and revises the plan. Data collection involves gathering relevant information about the patient. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

hypoxia.

Clubbing is a sign of prolonged hypoxia. Causes of clubbing include emphysema, chronic bronchitis, lung cancer, and heart failure. Beau's lines (transverse depressions in the nail that extend beyond the nail bed) occur with acute illness, malnutrition, and anemia. Koilonychia (thin, spoon-shaped nails with lateral edges that tilt upward) is associated with Raynaud's disease, malnutrition, chronic infections, and hypochromic anemia. Onycholysis (loosening of the nail plate with separation from the nail bed) is associated with hyperthyroidism, psoriasis, contact dermatitis, and Pseudomonas infections.

Deficient fluid volume

Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock will cause a decrease in cardiac output. Tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

Reinforce the dressing and contact the physician.

The nurse should reinforce the dressing and notify the physician. A saturated dressing might signal postoperative hemorrhage. Continuing to monitor the client without notifying the physician delays treatment. The nurse should also monitor the client's vital signs. The first postoperative dressing should be changed by the physician, not the nurse.

circadian rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle

stethescope; diaphragm; bell and palpation

The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.

dividing the body into sections

A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?

During the evaluation step of the nursing process, the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met, the nurse reexamines the data and revises the plan. Data collection involves gathering relevant information about the patient. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

candidiasis

yeast infection; infections occurring on the skin or mucous membranes in the warm, moist areas such as the vagina or the mouth

Which factor in a client's history indicates she's at risk for candidiasis?

Use of corticosteroids
Explanation: Small numbers of the fungus Candida albicans commonly inhabit the vagina. Because corticosteroids decrease host defense, they increase the risk of candidiasis. Pregnancy, not nulliparity, increases the risk of candidiasis. Candidiasis is rare before menarche and after menopause. The use of hormonal contraceptives, not spermicidal jelly, increases the risk of candidiasis.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take?

Notify the nursing supervisor and approach the individual.
Explanation: Approaching the person and requesting the client's medical record isn't sufficient considering the confidential health care information. Notifying the nursing supervisor, then approaching the individual before informing the client provides the most appropriate approach to this breech of client confidentiality. Contacting security might not be warranted unless the nurse learns the reason the unauthorized individual was reading the client's chart. The nurse should also document the incident according to facility policy.

A client with a history of chronic renal failure is admitted with pulmonary edema following a missed dialysis treatment yesterday. His laboratory results are serum potassium 6.0 mEg/L, serum sodium 130 mEg/L, and serum bicarbonate 18 mEg/L. The nurse interprets that the client has which of the following conditions?

Hyperkalemia
Explanation: The kidneys are responsible for excreting potassium. In renal failure, the kidneys can no longer excrete potassium, resulting in hyperkalemia. The kidneys are responsible for regulating the acid-base balance; in renal failure, acidemia, not alkalemia, would be likely. Generally, hyponatremia, not hypernatremia, would occur because of the dilutional effect of water retention. Hypokalemia is generally seen in clients undergoing diuresis.

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake?

Serving fluids in large amounts
Explanation: Fluids should be served in small amounts at frequent intervals. It's overwhelming to the client to have large amounts of fluids to drink. Teaching the client about the need for fluid increase and including him in the selection of beverages will enhance compliance. Fluids should be served at the appropriate temperatures to increase enjoyment and palatability.

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.
Explanation: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.

The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important?

Increasing fluid intake to 3 L/day
Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

middle-old

Ages 75-84

young-old

65-74 years of age

old-old

85 years of age and older

young-old to old-old and frail elderly explaination

A 76-year-old client with no debilitating conditions belongs to the middle-old geriatric population. The young-old geriatric population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is another group, the frail elderly, which includes all individuals older than age 65 who have one or more debilitating conditions.

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:

water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
Explanation: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to the inability of the kidneys to excrete hydrogen ions.

When reviewing the history of a client with Crohn disease, which factor would the nurse associate with this disorder?

Heredity
Explanation: Although the definitive cause of Crohn disease is unknown, it's thought to be associated with infectious, immune or psychological, factors. Because it has a higher incidence in siblings, it may have a genetic cause. Constipation isn't linked to Crohn disease. On the contrary, Crohn disease causes bouts of diarrhea. Diet may contribute to exacerbations of Crohn disease but isn't considered a cause. A lack of exercise isn't considered a cause of Crohn disease.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool."
Explanation: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

Which condition most commonly results in coronary artery disease (CAD)?

Atherosclerosis
Explanation: Atherosclerosis, or plaque formation, is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD but isn't the most common cause. Renal failure doesn't cause CAD, but the two conditions are related. MI is commonly a result of CAD.

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter but doesn't show signs of active tuberculosis. Management of her care would include:

advising her to begin prophylactic therapy with isoniazid (INH).
Explanation: Individuals who are tuberculin skin test converters should begin a 6-month regimen of an antitubercular drug such as INH, and they should never have another skin test. After an individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin reactions but won't provide new information about the client's TB status. The client doesn't have active TB, so she can't transmit, or spread, the bacteria. Therefore, she shouldn't be quarantined or asked for information about recent contacts.

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:

a chest X-ray.
Explanation: Chest X-ray confirms whether the chest tube has resolved the pneumothorax. If the chest tube hasn't resolved the pneumothorax, the chest X-ray will reveal air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.

A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion
Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Option 1 is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option 2 is inappropriate because no evidence suggests that this client has a excessive fluid volume. Option 3 may be warranted but is secondary to ineffective tissue perfusion.

After an anterior wall myocardial infarction (MI), which problem is indicated by auscultation of crackles in the lungs?

Left-sided heart failure
Explanation: The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.

A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take?

Ask the client for a copy of the advance directive to place on his chart.
Explanation: Upon admission, a client should be asked if he has an advance directive and informed of his right to create one. If the client has an advance directive, a copy of the document must be placed in the medical record. It isn't enough just to note that the client has one. It would be incorrect to tell the client to give the directive to his lawyer or to imply that the directive isn't valid when surgery is being performed.

When checking a client's I.V. insertion site, the nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Check the tubing for kinks and reposition the client's wrist and elbow.
Explanation: The nurse should first check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge clots, if present. Elevating the I.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.

A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone (Celestone) 12 mg I.M. q 24 hours × 2. What is the expected outcome of this drug therapy?

The neonate will be delivered with mature lungs.
Explanation: Betamethasone is a corticosteroid that induces the production of surfactant. The pulmonary maturation that results causes the fetal lungs to mature more rapidly than normal. Because the lungs are mature, the risk of respiratory distress in the neonate is lowered but not eliminated. Betamethasone also decreases the surface tension within the alveoli. Betamethasone has no influence on contractions or carrying the fetus to full term. It also does not prevent infection.

Which of the following clients would be most susceptible to experiencing ketoacidosis?

A client with type I diabetes
Explanation: The most common need for urine testing is the test for ketones if a client's blood glucose level is consistently high. Because only clients with type 1 diabetes are susceptible to diabetic ketoacidosis, these clients learn to test their urine for ketones if their blood glucose readings exceed 240 mg/dL.

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving deoxygenated blood from the venous system?

Right atrium
Explanation: The right atrium receives deoxygenated blood from the venous system.

A child diagnosed with insulin-dependent diabetes mellitus is attending a camp for diabetic children. He gives himself regular insulin and insulin zinc suspension (Humulin L) at 8 a.m. The nurse should plan to observe him for signs and symptoms of hypoglycemia resulting from the effects of the Humulin L insulin between which of the following times?

2 p.m. and 5 p.m.
Explanation: The action of an intermediate-acting insulin such as insulin zinc suspension (Humulin L) begins 1 to 3 hours after injection and peaks 6 to 12 hours after injection. The child is most at risk for hypoglycemia at the times when the insulin would peak, in this case beginning between 2 p.m. and 5 p.m.

A patient develops diarrhea secondary to antibiotic therapy. He is to receive two tablets of diphenoxylate HCl with atropine sulfate (Lomotil) orally as needed for each loose stool. The nurse should inform him that he may experience

dizziness.
Explanation: The most common adverse effects of diphenoxylate HCl with atropine sulfate are drowsiness and dizziness related to the drug's chemical similarity to meperidine, an opioid. Tachycardia is an adverse effect, not bradycardia. Muscle aches and an increase in appetite are not adverse effects of the drug.

A client is prescribed metformin (Glucophage) to control type 2 diabetes. The nurse should monitor for which life-threatening adverse reaction?

lactic acidosis

An elderly client tells the nurse that he doesn't want to take a bath. Which action by the nurse is most appropriate?

Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him bathe
Explanation: It's important for the client to understand why a bath is important to overall health. Communicating with the client shows respect and aids compliance. Giving the client a specific time for the bath allows him time to prepare for the care. Documenting bath refusal, calling the physician, and contacting family members are inappropriate before discussing the importance of the bath with the client and reattempting to provide care.

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

Notify the charge nurse so she can notify the physician of the missed dose.
Explanation: An error was made that needs to be addressed by notifying the charge nurse. The charge nurse should then notify the physician to determine if the medication is still appropriate for the client, and then request the medication from the pharmacy if it's still needed. The physician might order a potassium level to see if the dose is sufficient for the client. It isn't appropriate to ask the client if the medication is still needed. After the charge nurse and physician have been notified, the nurse should document the incident according to facility policy.

Which statement best describes an expected outcome?

Goals that the client should reach as a result of planned nursing interventions
Explanation: Expected outcomes are realistic, measurable goals that include target dates for when the goals will be achieved. They're devised by the nursing staff with input from the client. The goals are attained by following planned nursing interventions.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne- Stokes respirations are:

progressively deeper breaths followed by shallower breaths with apneic periods.
Explanation: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion?

Instructing the client to report any itching, swelling, or dyspnea
Explanation: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should monitor vital signs 5 minutes after the transfusion is started, again in 15 minutes, and then at least hourly depending on the client's condition.

A client states that he has 20/40 vision. Which statement about this client's vision is true?

The client can read from 20' (6 m) what a person with normal vision can read from 40'.
Explanation: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance an eye with normal vision can read the chart. Normal vision is defined as 20/20. The other options are inaccurate.

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation.
Explanation: The pulse and respiratory rates normally increase during and for a short time after ambulation, especially if it's the first ambulation after 3 days of bed rest. A normal walking pace is 70 to 100 steps/minute; a much slower pace may indicate distress. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds the head erect, gazes straight ahead, and keeps the toes pointed forward; option 3 describes a client with activity intolerance.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?

The client's arms are fully extended when using the walker.
Explanation: When using a walker, the client's arms should be slightly bent at the elbow, allowing maximum support from the arms while ambulating. The weak leg is always moved forward first with the walker to provide the maximum support. When sitting, the client should always back up to the chair and feel the chair with his legs before sitting. The client should use the armrests of the chair for support because the armrests are more stable than the walker.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:

left calf circumference 1" (2.5 cm) larger than the right.
Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Hypokalemia
Explanation: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

The following statement appears on a client's plan of care: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of:

a client outcome.
Explanation: A client outcome is a short- or long-term goal based on projected nursing interventions. A nursing diagnosis is a statement about a client's actual or potential problem. Subjective data are information relayed to the nurse by the client. A nursing intervention is an action the nurse takes in response to a client's problem.

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