MED/SURG NCLEX-RN HESI PRACTICE, HESI Med Surg 1, HESI MED SURG #1 TEST, ACLS practice questions

Term
1 / 908
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?

A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds.
Click the card to flip 👆
Terms in this set (908)
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?

A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds.
B
The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B).
During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?

A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine."
A
Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).
During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?

A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin
C
All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C).
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

A.Restore skin integrity.
B.Prevent infection.
C.Promote healing.
D.Improve nutrition.
B
The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable goals. (D) is important but of less priority than (B).
The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)

A.Encourage alcohol and smoking cessation.
B.Suggest supplementing diet with vitamin E.
C.Promote regular weight-bearing exercises.
D.Implement a home safety plan to prevent falls.
E.Propose a regular sleep pattern of 8 hours nightly.
A, C, D
(A, C, and D) are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss (B). Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis (E).
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated?

A.Help the client determine ways to increase his fluid intake.
B.Obtain an appointment for the client to have an eye examination.
C.Instruct the client to use oxygen at night and increase the humidification.
D.Schedule the client for tests to determine his sensitivity to cat hair.
A
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client, who depends on his pet for socialization.
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?

A.Urine specific gravity of 1.03
B.Frothy, tea-colored urine
C.Clay-colored stools
D.Elevated serum amylase and lipase levels
D
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice.
Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.)

A.Encourage annual physical and Pap smear.
B.Take antiviral medication as prescribed.
C.Use condoms to avoid transmission to others.
D.Warm sitz baths may relieve itching.
E.Use Nystatin suppositories to control itching.
F.Use a douche with weak vinegar solution to decrease itching.
A, B, C, D
The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and (F) is used to treat Trichomonas.
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?

A.Recommend mental health counseling.
B.Review the medication actions and interactions.
C.Assess for the client's daily activity level.
D.Provide information regarding a support group.
B
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed.
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

A.Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
B.Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.
C.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
D.Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.
C
Placing the client in a supine position (C) reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. (A) compromises diaphragmatic expansion and inhibits pressoreceptor activity. (B) places the client at risk of evisceration of the abdominal wound and increased bleeding. (D) will not stop internal bleeding in the liver and spleen caused by the gunshot wound.
The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A.Tall, spiked T waves B.A prolonged QT interval C.A widening QRS complex D.Presence of a U waveD A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A.Albumin B.Calcium C.Glucose D.Alkaline phosphataseC TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? A.Failing eyesight resulting in an unsafe environment B.Renal osteodystrophy resulting from chronic kidney disease (CKD) C.Osteoporosis resulting from declining hormone levels D.Cerebral vessel changes causing transient ischemic attacksC The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. (B) is not a common condition of older people but is associated with CKD. Although (D) may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy.D Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered.A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not requiredB The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push.B With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion (B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A.Pedal pulses will be weak or absent in the left foot. B.The client will state that the left foot is usually warm. C.Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk.A Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client.A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake.D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention.During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A.Review the client's history for diabetes mellitus. B.Observe the extremity distal to the IV site. C.Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds.C Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (C).A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care.A Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A.Document this expected decrease in drainage. B.Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing.D The least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fractureB The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased the BUN level (B). (A) would affect serum enzyme levels, not the BUN level. (C) would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of (D) might affect the complete blood count (CBC) but would not directly increase the BUN level.The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemiaB Clients with angle-closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, and D) do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A.The vaccine is given annually before the flu season to those older than 50 years. B.The immunization is administered once to older adults or those at risk for illness. C.The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D.The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.B It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime (B). Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year, not Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A.The client's amylase level is three times higher than the normal level. B.While the nurse is taking the client's blood pressure, he has a carpal spasm. C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D.The client states that he will continue to drink alcohol after going home.B A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign.During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake.A The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap (A). Lasix IV is not indicated for treatment of pericarditis (B). Because the client's breath sounds are clear, (C) is not a priority. Fluids are frequently increased (D) in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as (A).After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A.Switch to skim milk. B.Switch to orange juice. C.Add a source of protein. D.Add herbal tea.A Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. (A) promotes reduced fat consumption. Orange slices provide more fiber than orange juice (B, C, and D) are not standard recommendations for reducing cancer risk.A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A.Support the client to a sitting position. B.Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula.A The nurse should safely assist the client to a resting position (A) and then perform (C and D). The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B).A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A.Fever of 102° F B.Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranesA A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately (A). (B, C, and D) are also findings that require intervention by the nurse, but are of less priority than (A). (B) may indicate a hypertensive condition but is not as acute a condition as peritonitis. (C) is an expected finding in clients with small bowel obstruction and may require medication. (D) indicates probable fluid volume deficit, which requires fluid volume replacement.A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A.Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B.Move clients and visitors into the hallways and close all doors to clients' rooms. C.Visually confirm the location of the tornado by checking the windows on the unit. D.Assist all visitors with evacuation down the stairs in a calm and orderly manner.B In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury (B). Although (A) may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; (B) is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than (C). (D) is not the first action that should be taken.A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for restD Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed because the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstructionD CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve (D) with the return of an adequate glomerular filtration rate and, when it does, dialysis will no longer be needed. (A, B, and C) are manifestations seen in the acute and chronic forms of kidney disease.Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A."Get immunization against human papillomavirus (HPV)." B."Change your tampon frequently." C."Empty your bladder after intercourse." D."Obtain a yearly flu vaccination."B Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently (B) reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. (A) helps prevent cervical cancer, not toxic shock syndrome. (C) can lessen the incidence of urinary tract infection. (D) can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medicationC Administration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse but are of less priority than (C).A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A.Follow exposure precautions. B.Encourage regular meals. C.Collect all urine. D.Avoid touching the client.Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure (A) that would pose a hazard to others. (B) is a good suggestion to promote adequate nutrition but is not as important as (A). (C) is unnecessary. Contact with the client (D) IS permitted but should be BRIEF to limit radiation exposure.An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A.Initiate airborne infection precautions. B.Place a surgical mask on the client. C.Don an isolation gown and latex gloves. D.Start protective (reverse) isolation precautions.This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions (A), which are indicated for TB, should be used with this client. (B) is used with DROPLET precautions. There is no evidence that (C or D) would be warranted at this time.Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels D.KetonuriaB Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end-stage renal disease caused by diabetic nephropathy. (C) may be elevated in end-stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA).An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardiaD The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia.Which nursing action is necessary for the client with a flail chest? A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing.D Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph.When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis C.A female client in isolation with meningococcal meningitis D.A male client 1 day postoperative after drainage of a brain abscessB The most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times. C.Tell the client to carry a medical alert card that explains his condition. D.Caution the client not to travel outside the United States alone.C Neck breathers carry a medical alert card (C) that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages (B) is probably the least effective.A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A.Assess for signs of jugular venous distention. B.Obtain the needed intravenous solution. C.Flush the line with heparinized solution. D.Flush the line with normal saline.D Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution (D) to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin (C). (A) will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than (B).In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A.The client has a rigid hard abdomen and elevated WBC. B.The client has left lower quadrant pain and an elevated temperature. C.The client is refusing to eat any of the meal and is complaining of nausea. D.The client has not had a bowel movement in 2 days and has a soft abdomen.A A hard rigid abdomen and elevated WBC is indicative of peritonitis (A), which is a medical emergency and should be reported to the health care provider immediately. (B and C) are expected clinical manifestations of diverticulitis. (D) does not warrant immediate intervention.The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A."I will read all the teaching booklets you gave me before surgery." B."I have had surgery before, so I know what to expect afterward." C."All the things people have told me will help me take care of my back." D."Let me show you the method of turning I will use after surgery."D The outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14-year-old client may or may not follow through with (A), and there is no measurement of learning. (B) may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In (C), the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A.If suctioning will be needed for drainage of the wound B.If the family would prefer a private or semiprivate room C.If the client also has a Hemovac in place D.If the client's wound is infectedD The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected (D). Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require (A). Although (B) is helpful information, it does not have the priority of (D). A Hemovac (C) is used to drain fluid from a dead space and is not a determinant for the room assignment.The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A."Have you ever experienced any paralysis of your arms or legs?" B."Do you have frequent blackout spells?" C."Have you ever been frozen in one spot, unable to move?" D."Do you have headaches, especially ones with throbbing pain?"C Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not typically cause (A, B, or D).A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding.B A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test resultsC The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia (C). (A, B, and D) will not be significantly affected by the removal of blood.During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take? A.Continue with the shift report and talk to the nurse about the incident at a later time. B.Ask the nurse to call the house supervisor to see if she must be reassigned. C.Stop the shift report and remind the nurse that all staff are floated equally. D.Inform the nurse that her behavior is disruptive to the rest of the staff.A Continuing with the shift report (A) is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. (B) encourages the nurse to shirk the float assignment. (C) is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private (D).The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A."Hold the medication in your mouth for a few minutes before swallowing it." B."Do not drink or eat milk products for 1 hour prior to taking this medication." C."Dilute the medication with juice to reduce the unpleasant taste and odor." D."Take the medication before meals to promote increased absorption."A Mycostatin is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow (A). (B) does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness (C). (D) is not necessary.Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A.Stress incontinence B.Infection C.Painless gross hematuria D.PeritonitisB Infection (B) is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. (C) is the most common symptom of bladder cancer. (D) is the most common and serious complication of peritoneal dialysis.A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A.Replace the stoma appliance every day. B.Use warm tap water to irrigate the ileostomy. C.Change the bag when the seal is broken. D.Measure and record the ileostomy output.C A seal must be maintained to prevent leakage of irritating liquid stool onto the skin (C). (A) is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so (B) is not necessary. (D) is not needed.In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution.C Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider (C) so that intervention can be initiated to restore function of the shunt. (A) is incorrect. (B) will not resolve the obstruction. An AV shunt is internal and cannot be flushed (D) without access using special needles.The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B.Exhibit regular, soft-formed stool within 1 month. C.Demonstrate the irrigation procedure correctly within 1 week. D.Attend an ostomy support group within 2 weeks.D Attending a support group (D) will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. (A) is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish (B). (C) is not necessary.A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify dose.A The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered (A). (B and C) would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, (D) is not necessary.A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A.NPO except for metformin and regular snacks B.NPO except for oral antidiabetic agent C.Novolin N insulin subcutaneously twice daily D.Regular insulin subcutaneously per sliding scaleD Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery (D). (A) increases the risk of vomiting and aspiration. (B and C) provide less precise control of the blood glucose level.The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most likely to exhibit? A.Polyuria B.Polydipsia C.Weight loss D.InfectionD Signs and symptoms of hyperglycemia in older adults may include fatigue, infection (D), and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as (A, B, and C) and polyphagia, may be absent in older adults.The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client INDICATES UNDERSTANDING of the teaching? (Select all that apply.) A.White bread B.Salmon C.Broccoli D.Whole milk E.BananaB, C, E (B, C, and E) provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk (D) is high in fat and is not recommended by ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes (A).A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A.Notify the family that the resident will have to be discharged if his behavior does not improve. B.Notify administration of the PN's insubordination and need for counseling about her statements. C.Ask the PN what she has done to encourage the resident to believe that she is his daughter. D.Reassign the PN until the resident can be assessed more completely for reality orientation.D Temporary reassignment (D) is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. (A) is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination (B). Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted (C).The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A.A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B.An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C.A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D.A recovering IV heroin user who contracted hepatitis more than 10 years agoA The diabetic teacher (A) has assumed responsibility for self-care, so among those listed, is the most likely to maintain optimum health. (B) has expressed a lack of interest in health promotion. (C) continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis (D) make this individual a health risk despite the fact that the individual is in recovery.What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A.Reducing dairy products in the diet B.Straining all urine C.Measuring intake and output D.Increasing fluid intakeB Straining all urine (B) is the most important nursing action to take in this case. Encouraging fluid intake (D) is important for any client who may have a kidney stone, but is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. (C) is not the highest priority action. (A) is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A.Place the client on NPO status. B.Assess the client's temperature. C.Obtain a stool specimen. D.Administer IV fluids.A A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO (A) to reduce risk of intestinal rupture. (B, C, and D) are important but are less of a priority than (A), which is implemented to prevent a severe complication.The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A.Fluid volume deficit B.Self-care deficit C.Risk for infection D.Impaired nutritionC The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection (C) because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing (A, B, or D), these problems are not the primary reason for the provision of frequent oral care.A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A.Turns on the continuous wall suction to −190 mm Hg B.Inserts the catheter until resistance or coughing occurs C.Withdraws the catheter while maintaining suctioning D.Reclears the tracheostomy after suctioning the mouthB (B) indicates correct technique for performing suctioning. Suction pressure should be between −80 and −120 mm Hg, not −190 mm Hg (A). The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction (C). (D) introduces pathogens unnecessarily into the tracheobronchial tree.A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A.Hypophosphatemia B.Hypocalcemia C.Hyponatremia D.HypokalemiaB Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A). Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with (C or D).The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?A.Measure the urine specific gravity.B.Obtain IV fluids for infusion per protocol.C.Prepare for insertion of a central venous catheter.D.Auscultate the client's breath sounds.BThe client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B).During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?A."Pace your activities and schedule rest periods."B."Increase the amount of oxygen you use at night."C."Obtain medical evaluation for antibiotic therapy."D."Reduce your intake of fluids containing caffeine."AManifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?A.Continuous IV infusion of magnesiumB.One-time infusion of albuminC.Continuous epidural infusion of morphineD.Intermittent infusion of IV vancomycinCAll four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C).The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?A.Restore skin integrity.B.Prevent infection.C.Promote healing.D.Improve nutrition.BThe prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable goals. (D) is important but of less priority than (B).The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)A.Encourage alcohol and smoking cessation.B.Suggest supplementing diet with vitamin E.C.Promote regular weight-bearing exercises.D.Implement a home safety plan to prevent falls.E.Propose a regular sleep pattern of 8 hours nightly.A, C, D(A, C, and D) are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss (B). Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis (E).An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated?A.Help the client determine ways to increase his fluid intake.B.Obtain an appointment for the client to have an eye examination.C.Instruct the client to use oxygen at night and increase the humidification.D.Schedule the client for tests to determine his sensitivity to cat hair.AClients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client, who depends on his pet for socialization.The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?A.Urine specific gravity of 1.03B.Frothy, tea-colored urineC.Clay-colored stoolsD.Elevated serum amylase and lipase levelsDObstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice.Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.)A.Encourage annual physical and Pap smear.B.Take antiviral medication as prescribed.C.Use condoms to avoid transmission to others.D.Warm sitz baths may relieve itching.E.Use Nystatin suppositories to control itching.F.Use a douche with weak vinegar solution to decrease itching.A, B, C, DThe nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and (F) is used to treat Trichomonas.The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?A.Recommend mental health counseling.B.Review the medication actions and interactions.C.Assess for the client's daily activity level.D.Provide information regarding a support group.BInterferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed.A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?A.Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.B.Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.C.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.D.Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.CPlacing the client in a supine position (C) reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. (A) compromises diaphragmatic expansion and inhibits pressoreceptor activity. (B) places the client at risk of evisceration of the abdominal wound and increased bleeding. (D) will not stop internal bleeding in the liver and spleen caused by the gunshot wound.The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?A.Tall, spiked T wavesB.A prolonged QT intervalC.A widening QRS complexD.Presence of a U waveDA U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?A.AlbuminB.CalciumC.GlucoseD.Alkaline phosphataseCTPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?A.Failing eyesight resulting in an unsafe environmentB.Renal osteodystrophy resulting from chronic kidney disease (CKD)C.Osteoporosis resulting from declining hormone levelsD.Cerebral vessel changes causing transient ischemic attacksCThe most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. (B) is not a common condition of older people but is associated with CKD. Although (D) may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement?A.Hang the solution at the current rate.B.Refrigerate the solution until needed.C.Prepare the solution with new tubing.D.Return the solution to the pharmacy.DOnly regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered.A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?A.Immediately after feedingB.Just prior to tube feedingC.Continuous inflation is requiredD.Inflation is not requiredBThe cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?A.Administer lidocaine,75 mg intravenous push.B.Perform synchronized cardioversion.C.Defibrillate the client as soon as possible.D.Administer atropine, 0.4 mg intravenous push.BWith uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion (B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?A.Pedal pulses will be weak or absent in the left foot.B.The client will state that the left foot is usually warm.C.Flexion and extension of the left foot will be limited.D.Capillary refill of the client's left toes will be brisk.ASymptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client.A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?A.Avoid high-carbohydrate foods.B.Decrease intake of fat-soluble vitamins.C.Decrease caloric intake.D.Restrict salt and fluid intake.DSalt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention.During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?A.Review the client's history for diabetes mellitus.B.Observe the extremity distal to the IV site.C.Monitor the client's serum potassium and blood glucose levels.D.Evaluate the client's oxygen saturation and breath sounds.CClients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (C).A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?A.Determine if all employees have had the hepatitis B vaccine series.B.Explain that this type of hepatitis can be transmitted when feeding the client.C.Assure the employees that they cannot contract hepatitis B when providing direct care.D.Tell the employees that wearing gloves and a gown are required when providing care.AHepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?A.Document this expected decrease in drainage.B.Clamp the chest tube while assessing for air leaks.C.Milk the tube to remove any excessive blood clot buildup.D.Assess for kinks or dependent loops in the tubing.DThe least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding?A.Myocardial infarction 2 months agoB.Anorexia and vomiting for the past 2 daysC.Recently diagnosed type 2 diabetes mellitusD.Skeletal traction for a right hip fractureBThe blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased the BUN level (B). (A) would affect serum enzyme levels, not the BUN level. (C) would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of (D) might affect the complete blood count (CBC) but would not directly increase the BUN level.The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?A.Antianginal with a therapeutic effect of vasodilationB.Anticholinergic with a side effect of pupillary dilationC.Antihistamine with a side effect of sedationD.Corticosteroid with a side effect of hyperglycemiaBClients with angle-closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, and D) do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine?A.The vaccine is given annually before the flu season to those older than 50 years.B.The immunization is administered once to older adults or those at risk for illness.C.The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.D.The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.BIt is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime (B). Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year, not Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse?A.The client's amylase level is three times higher than the normal level.B.While the nurse is taking the client's blood pressure, he has a carpal spasm.C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.D.The client states that he will continue to drink alcohol after going home.BA positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign.During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?A.Prepare the client for a pericardial tap.B.Administer intravenous furosemide (Lasix).C.Assist the client to cough and breathe deeply.D.Instruct the client to restrict the oral fluid intake.AThe client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap (A). Lasix IV is not indicated for treatment of pericarditis (B). Because the client's breath sounds are clear, (C) is not a priority. Fluids are frequently increased (D) in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as (A).After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation?A.Switch to skim milk.B.Switch to orange juice.C.Add a source of protein.D.Add herbal tea.ADietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. (A) promotes reduced fat consumption. Orange slices provide more fiber than orange juice (B, C, and D) are not standard recommendations for reducing cancer risk.A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?A.Support the client to a sitting position.B.Ask the client to walk slowly back to the room.C.Administer a sublingual nitroglycerin tablet.D.Provide oxygen via nasal cannula.AThe nurse should safely assist the client to a resting position (A) and then perform (C and D). The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B).A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse?A.Fever of 102° FB.Blood pressure of 150/90 mm HgC.Abdominal crampingD.Dry mucous membranesAA sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately (A). (B, C, and D) are also findings that require intervention by the nurse, but are of less priority than (A). (B) may indicate a hypertensive condition but is not as acute a condition as peritonitis. (C) is an expected finding in clients with small bowel obstruction and may require medication. (D) indicates probable fluid volume deficit, which requires fluid volume replacement.A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first?A.Instruct the nursing staff to close all window blinds and curtains in clients' rooms.B.Move clients and visitors into the hallways and close all doors to clients' rooms.C.Visually confirm the location of the tornado by checking the windows on the unit.D.Assist all visitors with evacuation down the stairs in a calm and orderly manner.BIn the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury (B). Although (A) may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; (B) is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than (C). (D) is not the first action that should be taken.A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client?A.Vitamin K1 (AquaMEPHYTON), 5 mg IM dailyB.High-calorie, low-sodium dietC.Fluid restriction to 1500 mL/dayD.Pentobarbital (Nembutal sodium) at bedtime for restDSedatives such as Nembutal (D) are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed because the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?A.AzotemiaB.OliguriaC.HyperkalemiaD.Nephron obstructionDCKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve (D) with the return of an adequate glomerular filtration rate and, when it does, dialysis will no longer be needed. (A, B, and C) are manifestations seen in the acute and chronic forms of kidney disease.Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?A."Get immunization against human papillomavirus (HPV)."B."Change your tampon frequently."C."Empty your bladder after intercourse."D."Obtain a yearly flu vaccination."BCertain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently (B) reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. (A) helps prevent cervical cancer, not toxic shock syndrome. (C) can lessen the incidence of urinary tract infection. (D) can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?A.Hypoactive bowel sounds with abdominal distentionB.Client reports continued pain of 8 on a 10-point scaleC.Respiratory rate of 12 breaths/min, with O2 saturation of 85%D.Client reports nausea after receiving the medicationCAdministration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse but are of less priority than (C).A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?A.Follow exposure precautions.B.Encourage regular meals.C.Collect all urine.D.Avoid touching the client.Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure (A) that would pose a hazard to others. (B) is a good suggestion to promote adequate nutrition but is not as important as (A). (C) is unnecessary. Contact with the client (D) IS permitted but should be BRIEF to limit radiation exposure.An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client?A.Initiate airborne infection precautions.B.Place a surgical mask on the client.C.Don an isolation gown and latex gloves.D.Start protective (reverse) isolation precautions.This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions (A), which are indicated for TB, should be used with this client. (B) is used with DROPLET precautions. There is no evidence that (C or D) would be warranted at this time.Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?A.HypokalemiaB.MicroalbuminuriaC.Elevated serum lipid levelsD.KetonuriaBMicroalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end-stage renal disease caused by diabetic nephropathy. (C) may be elevated in end-stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA).An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?A.Leukocytosis and febrileB.Polycythemia and cracklesC.Pharyngitis and sputum productionD.Confusion and tachycardiaDThe onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia.Which nursing action is necessary for the client with a flail chest?A.Withhold prescribed analgesic medications.B.Percuss the fractured rib area with light taps.C.Avoid implementing pulmonary suctioning.D.Encourage coughing and deep breathing.DTreatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph.When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?A.A young adult with bacterial meningitis with recent seizuresB.An older adult client with pneumonia and viral meningitisC.A female client in isolation with meningococcal meningitisD.A male client 1 day postoperative after drainage of a brain abscessBThe most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first? A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Defibrillate the client at 200 J. D. Assess the client's pulse oximetry.B. Start cardiopulmonary resuscitation. Rationale: Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately (B). (A and C) are appropriate, but CPR is the priority action. The client is dying, and (D) does not address the seriousness of this situation.The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U waveD. Presence of a U wave Rationale: A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl)B. Magnesium sulfate Rationale: Because the client has chronic alcoholism, she is likely to have hypomagnesemia. (B) is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. (A and D) increase the QT interval, which can cause the torsades to worsen. (C) is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes.D. The client states that changes in the pulse and feelings of dizziness are significant changes. Rationale: Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output (D). The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider (A). (B) is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. (C) indicates symptoms of possible incisional infection or irritation but do not indicate pacer failure.The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client indicates understanding of the teaching? (Select all that apply.) A. White bread B. Salmon C. Broccoli D. Whole milk E. BananaB Salmon C Broccoli E. Banana Rationale: (B, C, and E) provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk (D) is high in fat and is not recommended by ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes (A).A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula.A. Support the client to a sitting position. Rationale: The nurse should safely assist the client to a resting position (A) and then perform (C and D). The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B).After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea.A. Switch to skim milk. Rationale: Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. (A) promotes reduced fat consumption. Orange slices provide more fiber than orange juice (B, C, and D) are not standard recommendations for reducing cancer risk.A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legsB. Upper torso Rationale: Stooped posture results in the upper torso (B) becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck (A) and feet and legs (D) are not the center of gravity in the older adult. Although the arms (C) comprise a part of the upper torso, they do not reflect the best and most complete answer.The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy.D. Return the solution to the pharmacy. Rationale: Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered.A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not requiredB. Just prior to tube feeding The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbowB. Deep unrelenting pain in the right arm Rationale: Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids, and neurovascular compromise (B). (A) is an expected finding. (C) related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. (D) is an expected finding.Based on the clinical manifestations of Cushing's syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing's syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.A. Monitor blood glucose levels daily. Rationale: Cushing's syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing's syndrome often develop diabetes mellitus. Monitoring of serum glucose levels (A) assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing's syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids (B). Fatigue is usually not an overwhelming factor in Cushing's syndrome, so an emphasis on the need for rest (C) is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended (D).Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties B. Sudden, stabbing, severe pain over the lip and chin C. Unilateral facial weakness and paralysis D. Difficulty in chewing, talking, and swallowingB. Sudden, stabbing, severe pain over the lip and chin Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V) (B). (A) would be characteristic of Ménière's syndrome (cranial nerve VIII). (C) would be characteristic of Bell's palsy (cranial nerve VII). (D) would be characteristic of disorders of the hypoglossal (cranial nerve XII).During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide (Lasix). C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict the oral fluid intake.A. Prepare the client for a pericardial tap. The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap (A). Lasix IV is not indicated for treatment of pericarditis (B). Because the client's breath sounds are clear, (C) is not a priority. Fluids are frequently increased (D) in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as (A).An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.B. Auscultate the client's breath sounds. Rationale: All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds (B) because the client may have a pulmonary embolus secondary to the thrombophlebitis. (A) may provide data that support the nurse's suspicion of thrombophlebitis. (C) is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. (D) is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycinC. Continuous epidural infusion of morphine All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C).One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? A. Provide a paper bag for his hyperventilation. B. Administer a prescribed PRN analgesic. C. Have the client drink a glass of sweetened fruit juice. D. Apply oxygen at 2 L via nasal cannula.D. Apply oxygen at 2 L via nasal cannula. Rationale: Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment (D). A rapid respiratory rate should not be treated as hyperventilation (A). (B) should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic (C).A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.B. Turn off the continuous feeding pump Rational: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.A. Provide a room that can be kept warm. Abnormal blood flow in response to cold (Raynaud's phenomenon) is precipitated (A) in clients with scleroderma. (B) is not a significant factor. Stress can also precipitate the severe pain of Raynaud's phenomenon, so a quiet environment is preferred to (C), which is often very noisy. (D) is not necessary.A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing care.A. Determine if all employees have had the hepatitis B vaccine series. Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscessB. An older adult client with pneumonia and viral meningitis Rationale: The most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? A. Recommend mental health counseling. B. Review the medication actions and interactions. C. Assess for the client's daily activity level. D. Provide information regarding a support group.B. Review the medication actions and interactions. Rationale: Interferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed.The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks.D. Attend an ostomy support group within 2 weeks. Rationale: Attending a support group (D) will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. (A) is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish (B). (C) is not necessary.A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A. Hypoactive bowel sounds with abdominal distention B. Client reports continued pain of 8 on a 10-point scale C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% D. Client reports nausea after receiving the medicationC. Respiratory rate of 12 breaths/min, with O2 saturation of 85% Rationale: Administration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse but are of less priority than (C).An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions.A. Initiate airborne infection precautions. Rationale: This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions (A), which are indicated for TB, should be used with this client. (B) is used with droplet precautions. There is no evidence that (C or D) would be warranted at this time.The nurse is caring for a client who is 1 day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation.B. Increase the client's oxygen flow rate. Rationale: Increasing the oxygen flow rate (B) provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. (A) can be delegated and is a lower priority action than (B). Defibrillation may eventually be necessary, but (C) is not the immediate treatment for frequent PVCs. (D) may become necessary if the client stops breathing, but is not indicated at this time.A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.C. Change the bag when the seal is broken. Rationale: A seal must be maintained to prevent leakage of irritating liquid stool onto the skin (C). (A) is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so (B) is not necessary. (D) is not needed.When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A. Albumin B. Calcium C. Glucose D. Alkaline phosphataseC. Glucose Rationale: TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.C. Monitor the client's serum potassium and blood glucose levels. Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (CA client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. HypokalemiaB. Hypocalcemia Rationale: Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A). Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with (C or D).A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation? A. Assess for bilateral jugular vein distention. B. Increase oxygen flow via nasal cannula. C. Administer PRN furosemide (Lasix). D. Auscultate for a pleural friction rub.B. Increase oxygen flow via nasal cannula. This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium (B). Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of (A), which does not exacerbate the ectopy. (C) could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of (D).Seconal, 0.1 g PRN at bedtime, is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. ½ tablet B. 1 tablet C. 1½ tablets D. 2 tablet15 gr= 1g 1 tabA female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.B. Reposition the client on her side. Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require (D)The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemiaB. Anticholinergic with a side effect of pupillary dilation Rationale: Clients with angle-closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, and D) do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstructionD. Nephron obstruction Rationale: CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve (D) with the return of an adequate glomerular filtration rate and, when it does, dialysis will no longer be needed. (A, B, and C) are manifestations seen in the acute and chronic forms of kidney disease.Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)B. Decrease in hemoglobin level Rationale: Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level (B). (A) indicates disease progression but is not a side effect of the medication. (C) is not related to methotrexate. (D) indicates that inflammation associated with the disease has diminished.A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment B. Renal osteodystrophy resulting from chronic kidney disease (CKD) C. Osteoporosis resulting from declining hormone levels D. Cerebral vessel changes causing transient ischemic attacksC. Osteoporosis resulting from declining hormone levels The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. (B) is not a common condition of older people but is associated with CKD. Although (D) may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.he nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home.B. While the nurse is taking the client's blood pressure, he has a carpal spasm. A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign.Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level.C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying (C). Laboratory findings in (A, B, and D) are not considered to be normal findings in an older adult.The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition.B. Preventing Infection Rationale: The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable goals. (D) is important but of less priority than (B).A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline.D. Flush the line with normal saline. Rationale: Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution (D) to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin (C). (A) will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than (B).A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is, "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.B. Call the anesthesia provider for a different medication for pain. Rationale: The nurse should call the provider for a different medication (B) because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. (A) is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, (C and D) both disregard the prescription and the client's need for pain relief in the immediate postoperative period.When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medical alert card that explains his condition. D. Caution the client not to travel outside the United States alone.C. Tell the client to carry a medical alert card that explains his condition. Rationale: Neck breathers carry a medical alert card (C) that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages (B) is probably the least effective.An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? . Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardiaD. Confusion and tachycardia Rationale: The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia.The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington's disease. Which care measure is most important for the nurse to supervise? A. Oral care B. Bathing C. Foot care D. Catheter careA. Oral care Rational: The client with Huntington's disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely (A). (B, C, and D) do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences.Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. KetonuriaB. Microalbuminuria Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end-stage renal disease caused by diabetic nephropathy. (C) may be elevated in end-stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA).Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia? A. Diarrhea related to medication side effects B. Anxiety related to fear of recurrent anginal episodes C. Altered nutrition related to high serum lipid levels D. Risk for injury related to syncope and confusionD. Risk for injury related to syncope and confusion Rationale: The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at risk of syncope and falling, as well as confusion (D). (A) is of high priority but less so than maintaining client safety. Clients may experience (B) as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the priority of (D). (C) also does not have the priority of (D).The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption."A. "Hold the medication in your mouth for a few minutes before swallowing it." Rationale: Mycostatin is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow (A). (B) does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness (C). (D) is not necessary.A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A. Warfarin (Coumadin) B. Ibuprofen (Motrin) C. Nitroglycerin (Nitrostat) D. Digoxin (Lanoxin)D. Digoxin (Lanolin) Ratioanle: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin (Lanoxin) or digitoxin (medications derived from digitalis) (D), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. (A, B, and C) are unlikely to result in the symptoms described.A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bonesC. Thinning of the skin, with loss of elasticity Thin nonelastic skin (C) is an important factor in pressure formation. The proportion of body fat to lean mass increases with age (A) and might help decrease ulcer tendency. (B) causes gray hair. (D) can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101° F D. Absence of chest tube drainage for 2 daysA. Tidaling of water in water seal chamber Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed (A) to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. (B) may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. (C) usually indicates an infection, which may not be related to the chest tube. (D) is an expected finding.A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A. Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Pentobarbital (Nembutal sodium) at bedtime for restD. Pentobarbital (Nembutal sodium) at bedtime for rest Rationale: Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed because the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider.D. Encourage the client to keep taking the drug until seen by the health care provider. Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication (D). Immediate evaluation is not needed (A). Antihypertensive medications should not be stopped abruptly (B) because rebound hypertension may occur. (C) is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination."B. "Change your tampon frequently." Rationale: Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently (B) reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. (A) helps prevent cervical cancer, not toxic shock syndrome. (C) can lessen the incidence of urinary tract infection. (D) can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; Paco2, 30 mm Hg; Pao2, 64 mm Hg; HCO3, 25 mEq/L; and Fio2, 0.80. Which intervention should the nurse implement first? A. Increase the ventilator VT to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the Fio2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP).D. Add 5 cm positive end-expiratory pressure (PEEP). Rationale: Adding PEEP (D) helps improve oxygenation while reducing Fio2 to a less toxic level. (A, B, and C) will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.Which nursing action is necessary for the client with a flail chest? A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing.D. Encourage coughing and deep breathing. Rationale: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph.The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test resultsC. Decreased serum ammonia level Rationale: The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia (C). (A, B, and D) will not be significantly affected by the removal of blood.The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.)A.Frequent vital signs. B.Determine if the client is allergic to aspirin. D.Offer fluids of choice. F.Monitor infusion of IV nitroglycerine.In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?C.Potassium Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign.The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.)A.Facial muscle spasms B.Sudden facial pain Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V).A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action should the nurse take first?D.Add 5 cm positive end-expiratory pressure (PEEP) Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic levelThe clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.)B."I will avoid forceful and deep coughing until my post-op checkup. C."I must lay flat on my non-operative side for the first 12 hours after surgery." D."My hearing may be less or muffled until the packing comes out." The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair washing is discouraged.During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take?A. Continue with the shift report and talk to the nurse about the incident at a later time. Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private.The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations that the client is likely to experience?C."Have you ever been frozen in one spot, unable to move?" Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move.The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.)B.Salmon C.Broccoli E.Banana Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA).Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome?A.Monitor blood glucose levels daily. Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin earlyA resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client?A.Determine if all employees have had the hepatitis B vaccine series. Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination.A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately?C.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound.While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select all that apply.)A.Yell, "Call 911." B.Ask the mother if she has the child's bronchodilator. E.Stay with the child and mother until the ambulance arrives. F.Sit the child straight up in Fowler's position.A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.)A.Nausea and vomiting B.Loss of appetite C.Abdominal cramping D.Guarding with abdominal palpationThe nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?D.Infection Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes).An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?B.Auscultate the client's breath sounds. All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis.The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement?D.Return the solution to the pharmacy. Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy.Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old who is in good health overall?C.Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying.A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first?B.Call the anesthesia provider for a different medication for pain. The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma.The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.)A.Apply heat packs to your knees as needed for pain. B.Support your knees while you are in bed with a pillow or a rolled towel. E.Get 7 to 8 hours of sleep every night. F.Eat a balanced diet, including fish with Omega-3 fatty acids.A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?B.Inserts the catheter until resistance or coughing occursDuring assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse take first?A.Prepare the client for a pericardial tap. The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap.A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine?B.The immunization is administered once to older adults or those at risk for illness. It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year.The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.)A.Frequent oral care every 2 hours while awake. B.Use incentive spirometer every 2 hours. C.Empty contents from NG tube every 8 hours. One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery.The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?B.Deep unrelenting pain in the right arm Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise.The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which action should the nurse take first?C.Document the presence of these assessment findings. A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings.The clinic nurse is preparing to teach a client about having a cardiac catheterization. What assessment must the nurse include in the teaching plan?B."Do you take any medication for Type II diabetes?" The iodine dye from the catheterization and metformin can cause the client to develop lactic acidosis. Metformin is held 24 hours before the procedure and up to 48 hours after the procedure.The nurse is teaching a group of elders at a senior center. Which is the most significant safety implication for this group that the nurse will include in the teaching plan?C.Stooped posture Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration.A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?B.Just prior to tube feeding The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory systemThe nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain?D.If the client's wound is infected The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room.The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?C.Decreased serum ammonia level The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia.The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?D.Elevated serum amylase and lipase levels Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury.When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching?C.Tell the client to carry a medical alert card that explains the condition. Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client.The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point?A.Around the waist The waist is the anchor point for the bandage for an above the knee amputation.Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.)A.Bean soup B.Spinach E.Dark chocolate F.ShellfishA client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?B.Hypocalcemia Hypocalcemia develops in CKD because of chronic hyperphosphatemiaThe nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?A.Tidaling of water in water seal chamber Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure.The nurse assesses a client who has been prescribed furosemide for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?D.Presence of a U wave A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level).Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?B.Microalbuminuria Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy?B.Decrease in hemoglobin level Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level.The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse take first?B.Review the medication actions and interactions. Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it is most important for the nurse to review the medication effects and report these to the health care provider.The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first?B.Obtain IV fluids for infusion per protocol. The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion.A 43-year-old homeless, malnourished client with a history of alcoholism is transferred to the ICU. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer?B.Magnesium sulfate The client with chronic alcoholism is likely to have hypomagnesemia.What element of a system of care is represented by properly functioning resuscitation equipment? System Structure Process Patient outcomeStructureWhat is the first link in the out-of-hospital cardiac arrest (OHCA) chain of survival? Activation of emergency response Defibrillation Advanced resuscitation High-quality CPRActivation of emergency reponseWhat are signs of clinical deterioration that would prompt the activation of rapid response system? Symptomatic hypertension Seizure Unexplained agitation Diastolic blood pressure greater than 60 mm Hg or less than 100 mm HgSymptomatic hypertension Seizure Unexplained agitationWhat is the primary purpose of a rapid response team (RRT) or medical emergency team (MET)? To provide diagnostic consultation to emergency department patients To improve care for patients admitted to critical care units To improve patient outcomes by identifying and treating early clinical deterioration To provide online consultation to emergency medical services personnel in the fieldTo improve patient outcomes by identifying and treating early clinical deteriorationWhat happens when teams rapidly assess and intervene when patients have abnormal vital signs? Morbidity and mortality rates are maintained The number of out of hospital cardiac arrest increases The number of in hospital cardiac arrest decreases Morbidity and mortality rates increaseThe number of in hospital cardiac arrest decreasesIn addition to decreased IHCA, what are some other benefits of implementing a rapid response system? Select all that apply Decreased ICU length of stay Decreased emergency department admissions Increased ICU admissions Increased Hospital Length of Stay Decreased in total hospital length of stayWhich is the main advantage of effective teamwork? Early defibrillation Division of tasks Mastery or resuscitation skills Immediate CPRDivision of tasksWhich is the best example of a role of the team leader? Proficient at endotracheal intubation Does not over ventilate the patient Performs within scope of practice Models excellent team behaviorModels excellent team behaviorWhich is the best example of a role of a team member? Monitors individual team members Helps train future team leaders Focuses on comprehensive patient care Prepared to fulfill their role responsibilitiesPrepared to fulfill their role responsibilitiesWhat is the primary purpose of the CPR coach on a resuscitation team? Recording CPR data Resolving team conflicts Increasing CPR quality Giving encouragementIncreasing CPR qualityWhat are the 6 positions for high performance teams in resuscitation?Team leader Airway Timer/recorder Compressor (rotate every 2 minutes) Monitor/defibrillator/cpr coach IV/IO/MedicationsWhich member of the high performance team has the responsibility for assigning roles (positions)? Compressor Time/recorder Airway Team leaderTeam leaderWhich high performance team member is part of the resuscitation triangle? Timer/recorder Monitor/defibrillator/Cpr coach IV/IO/medications Team leaderMonitor/defibrillator/cpr coachWhich is an example of knowledge sharing by a team leader? Changing a treatment strategy when supported by new information Maintaining an ongoing record of treatments Asking for suggestions about interventions Asking the compressor to decrease or increase rateAsking for suggestions about interventionsWhich is an example of summarizing and reevaluating? "1mg of epinephrine given" Questioning a colleague who is about to make a mistake "Compressions are at a good rate" Increasing monitoring if the patients condition deterioratesIncreasing monitoring of the patiWhich is a step of closed-loop communication? Confirming task completion before assigning another task Encouraging all team members to speak clearly Abandoning ego Using distinctive speech and a controlled voiceConfirming task completion before assigning another taskWhich are examples of mutual respect? Select all that apply: Acknowledging correctly completed task in a positive way Requesting a clear response and eye contact from the team member Giving drugs only after verbally confirming the order Ensuring that only 1 person talks at a timeAcknowledging correctly completed tasks in a positive way Ensuring that only one person talks at a timeWhat are the components of high quality CPR? Select all that apply: Synchronous ventilation with chest compressions Avoiding excessive ventilation Compression rate around 10/min Complete chest recoil after each compression Interruptions limited to less than or equal to 10 seconds Low coronary perfusion pressure Switching compressors every 2 minutes Compression depth of at least 2 inches (5cm)Compression depth of at least 2 inches (5cm) Switching compressors every 2 minutes Avoiding excessive ventilation Complete chest recoil after each compression Interruption limited to under 10 secondsHow do you calculate the chest compression fraction (CCF)? What is ideal percentage?Divide chest compression time by total code time. You want this at least 60% but ideally greater than 80%Which component of effective high-performance teams is represented by the use of real-time feedback devices? Quality Administration Timing CoordinationQualityHow do you calculate Coronary Perfusion Pressure (CPP)?Aortic diastolic pressure "minus" Right Atrial Diastolic PressureHow do interruptions in chest compressions negatively impact survival after cardiac arrest? Increase intracranial pressure Decrease coronary perfusion pressure Reduce right ventricular period Increase intrathoracic pressureDecrease coronary perfusion pressureWhat is the only intervention that can restore an organized rhythm in patients with ventricular fibrillation (VF)? High-quality CPR Epinephrine administration Early and effective defibrillation Advanced airway insertionEarly and effective defibrillationHow quickly does the chance of survival decline for every minute of defibrillation delay in patients with ventricular fibrillation who do receive bystander CPR? 3-4% 5-6% 11-13% 7-10%7-10%What is the advantage of a systematic approach to patient assessment? Reduces the need for secondary assessment Reduces the chance of missing important signs and symptoms Permits assessment modification based on patient symptoms Standardizes treatment across systems of careReduces the chances of missing important signs and symptomsWhat is the first step in the systematic approach to patient assessment? BLS assessment Initial impression Primary assessment Secondary assessmentInitial impressionWhat is the maximum amount of time you should simultaneously perform pulse and breathing checks? 10 seconds 5 seconds 20 seconds 15 seconds10 secondsWhile performing the BLS Assessment, you initiate high- quality CPR and assist ventilation with a bag mask device. The AED does not recommend a shock. Which action in the Primary assessment should you perform first? Determine if the patients airway is patent Asses the patients oxygen status Perform fluid resuscitation Attach a quantitative waveform capnography deviceDetermine is the patients airway is patentThe initial assessment reveals a conscious patient. The patients airway is patent and an advanced airway is not indicated. Which action in the primary assessment should you perform next? Remove clothing to perform a physical examination Check for neuro function Administer oxygen as needed Check for the presence of a pulseAdminister oxygen as neededWhich action is part of secondary assessment of a conscious patient? Give IV/IO fluids if needed Formulate a differential diagnosis Determine the patients level of consciousness Attach a monitor defibrillatorFormulate a differential diagnosisWhich of the following are the "H's" causes of reversible cardiac arrest? Select all that apply: Hyperkalemia/hypokalemia Hypertensive crisis Acidosis HELLP syndrome Hyperventilation Hypoxia Hypothermia Heydes syndrome Hypocalcemia HypovolemiaHypothermia Hypoxia Hyperkalemia/hypokalemia Hypovolemia Acidosis Hypocalcemia Hyperventilation Hypertensive crisisWhich of the following are the "T" causes of reversible cardiac arrest? Cardiac tamponade Deep vein thrombosis Thyrotoxicosis Coronary thrombosis Tension pneumothorax Pulmonary thrombosis Toxins Simple pneumothorax Thoracic outlet syndrome TachycardiomyopathyTension pneumothorax Toxins Cardiac tamponade Pulmonary thrombosis Coronary thrombosisWhat is the only intervention that can restore an organized rhythm in patients with ventricular fibrillation (VF)?Early and effective defibrillationWhat is the most common symptom of myocardial ischemia and infarction?Retrosternal chest painWhich demographic group experiencing acute coronary syndromes is more likely to present without chest pain? Smokers Patients taking B-blockers Females AdolescentsFemalesOxygen should be delivered to a patient who has obvious signs of heart failure if the oxygen saturation is less than?90%Obtaining a what is the most important assessment tool for a patient displaying signs and symptoms of acute coronary syndrome?12 lead ekgWhat is the time goal for how quickly you should complete a fibrinolytic checklist once the patient arrives in the emergency department?10 minutesWhen should oxygen be administered?If the patient is dyspneic or hypoxemic, has obvious signs of heart failure, or has an arterial o2 saturation that is less than 90% or unknown.Which is a contraindication to the administration of aspirin for the management of a patient with acute coronary syndromes? Shortness of breath Recent GI bleeding Nausea VomittingRecent GI bleedingWhat are the contraindications of nitroglycerin?-If patient has a confirmed inferior wall stemi or right ventricular infarction -avoid nitro if patient has hypotension, bradycardia, or tachycardia -if patient recently has taken sildenafil, vardenafil, or tadalafil in the past 24-48 hrsWhat is a physiological effect of nitroglycerin? Bronchodilation Reduces preload Binds to opioid receptors Platelet aggregation inhibitionReduces preloadWhich clinical findings represents a contraindication to the administration of nitroglycerin? Anterior wall infarction Posterior wall infarction Lateral wall infarction Confirmed right ventricular infarctionConfirmed right ventricular infarctionWhen is morphine indicated?In STEMI patients with severe chest discomfort that does not respond to nitratesWhat should you always monitor after giving morphine?Monitor BP and respiratory rateWhen should you use caution when giving morphine?Use caution when patient is in NSTE-ACS because of the association of mortalityIf someone starts developing hypotension after giving morphine or nitroglycerin?Administer fluidsWhich class of medications commonly given to patients with acute coronary syndrome may be adversely affected by morphine administration? B-blockers Calcium channel blockers Phosphodiasterase inhibitors Oral anti platelet medsOral anti platelet medsWhat is the benefit of morphine when given for management of acute coronary syndrome? Increases left ventricular preload Vasoconstriction Central nervous system preload Increases systemic vascular resistanceCentral nervous system analgesicYou obtain a 12-lead ECG in a patient with retrosternal chest pain. Which ECG finding is suggestive of high risk non-ST-segment elevation acute coronary syndrome? ST-depression less than 0.5mm New left Bundle branch block ST-segment elevation Dynamic T-wave inversionDynamic t wave inversion????Upon reviewing a patients 12 lead ECG, you note ST segment elevation of 2mm in leads 2, 3, and aVF. How would you classify the ECG finding?ST-segment elevation myocardial infarctionWhat is the time goal for how quickly you should complete a fibrinolytic checklist once the patient arrives in the emergency department? 30 min 10 min 20 min 15 min10 minWhich action is part of the secondary assessment of a conscious patient? Determine the patients LOC Formulate a differential diagnosis Give IV/IO fluids if needed Attach a monitor/defibrillatorFormulate a differential diagnosisWhat do fibrinolytic meds end in?"ase"Upon reviewing a patients 12-lead ECG, you note ST-segment elevation of 2mm in leads II, III and aVF. How would you classify these ECG findings?ST-segment elevation myocardial infarctionWhat is the goal for first medical contact-to-balloon inflation time for a patient receiving percutaneous coronary intervention? 120 min 45 min 30 min 90 min90 minWhat is the longest acceptable emergency door to needle time when fibrinolysis is the indented reperfusion strategy? 15 min 30 min 45 min 60 min30 minWhat is the recommended window after symptoms onset for early fibrinolytic therapy or direct catheter based reperfusion for patients ST segment elevation myocardial infarction and no contraindications? Within 18 hours Within 12 hours Within 24 hours Within 48 hoursWithin 12 hoursWithin the first 10 minutes, on the basis of the patient showing symptoms suggestive of myocardial ischemia, what will your first actions include? Select all that apply Administer epinephrine 1 mg IV Administer a blood thinner Administer aspirin Assess airway, breathing, and circulation (ABCs) If considering prehospital fibrinolysis, use fibrinolytic checklist Provide prehospital notification to the receiving hospital Consider oxygen, nitroglycerin, and morphine if needed Obtain a 12 lead ECGAdminister aspirin Assess ABCs If considering prehospital fibrinolysis, perform fibrinolytic checklist Provide prehospital notification to the reveiving hospital Consider 02, nitro and morphine Obtain a 12 lead ECGUpon reviewing a patients 12 lead ECG, you note ST elevation of 2mm in leads II, III, and aVF. How would you classify these ECG findings? Non-st segment elevation MI ST-segment elevation myocardial infarction Normal findingsST segment elevation MIWhich action is part of the secondary assessment of a conscious patient? Attach a monitor/defibrillator Formulate a different diagnosis Determines patients LOC Give IV/IO fluids if neededFormulate a different diagnosisWhat is the most common type of stroke?Ischemic strokeWhat type of stroke occurs when a blood vessel in the brain suddenly ruptures into the surrounding tissue? Hemorrhagic stroke Transient ischemic attack Cryptogenic stroke Ischemic strokeHemorrhagic strokeWhich is a sign of a stroke? Abdominal pain Shortness of breath Trouble speaking Retrosternal chest painTrouble speakingWhich is a symptom of stroke? Diaphoresis Fever Sudden trouble seeing DiarrheaSudden trouble seeingWhat are the 3 components of the Cincinnati Prehospital stroke scale?Facial droop Arm drift Abnormal speechWhat is the estimated probability of the prehospital stroke scale with 1 abnormal finding when scored by prehospital providers? 72% 88% 80% 50%72%What is a stroke severity tool that helps EMS differentiate a large vessel occlusion stroke from a non-large vessel occlusion stroke? Miami emergency neurologic deficit score Cincinnati prehospital stroke scale Melbourne ambulance stroke screen Los Angeles Motor ScaleLos Angela's motor scaleWhat is the primary advantage of using a stroke severity tool? It helps identify large vessel occlusion stroke It helps determine the last known normal time It helps identify level of weakness It helps EMS providers identify signs of a strokeIt helps identify large vessel occlusion strokeWhat is the most appropriate destination for patients with suspected acute ischemic stroke? Certified stroke center Trauma center Hospital catheterization lab Closest emergency departmentCertified stroke centerWhat is the highest level of stroke center certification? Comprehensive stroke center Thrombectomy-capable stroke center Primary stroke center Acute stroke ready hospitalComprehensive stroke centerWhich is an advantage of EMS transport to a stroke hospital for a patient with a suspected acute ischemic stroke? Family members can ride to the hospital with the patient Responding providers can stabilize critical issues Patients transported by ambulance are seen first EMS transport is faster than being driven by a friendResponding providers can stabilize critical issuesWhat is an advantage of EMS alerting the receiving facility of the impending arrival of a patient with suspected acute ischemic stroke? The hospital can determine the most appropriate patient destination The hospital can have fibrinolytic drugs already prepared The emergency department can quickly determine glucose levels The hospital can perform more efficient evaluation and managementThe hospital can perform more efficient evaluation and managementWhat is the time for neurological assessment by the stroke team or designee and noncontrast computed tomography or magnetic resonance imaging performed after the hospital arrival? 20 min 25 min 15 min 10 min20 minWhat is the time goal for initiation of fibrinolytic therapy for patients w/o contraindications after hospital arrival45 minWhat is the door-to device time for direct-arriving patients with acute ischemic stroke treated with endovascular therapy?90 minEvidence suggest that there is a higher likelihood of good to excellent functional outcome when alteplase is given to adults with an acute ischemic stroke within what time frame? 12 hours 3 hours 24 hours 6 hours3hrsWhat is the maximum time for last known normal when endovascular therapy can be performed? 3hrs 12hrs 6hrs 24hrs24hrsWhat is the maximum time from last known normal when intra arterial thrombolysis for select patients can be used for treatment? 12hrs 3hrs 6hrs 4hrs6hrsWhat is the time goal for initiation of fibrinolytic therapy in appropriate patients without contraindications after hospital arrival? 30 min 45 min 35 min 40 min45 minIdentify the systolic blood pressure threshold for withholding fibrinolytic therapy to otherwise eligible patients with acute ischemic stroke.185 180 177 190Identify the diastolic blood pressure threshold for withholding fibrinolytic therapy to otherwise eligible patients with acute ischemic stroke. 110 105 115 100110What blood glucose level should trigger administration of IV or subq insulin for a patient with acute ischemic stroke? 170 160 150 180180What tidal volume typically maintains normal oxygenation and elimination of carbon dioxide? 12-14 ml/kg 6-8 ml/kg 9-11 ml/kg 3-5 ml/kg6-8How long should the second rescuer squeeze the bag mask device when providing 2-rescuer ventilation? 1 sec 3 sec 4 sec 2 sec1secWhen performing the jaw-thrust maneuver on patients with suspected cervical spine injury, where should you place your fingers? Just under the angle of the lower jaw Behind the patients ears Under the patients chin On top of the patients jawJust under the angle of the lower jawWhat is a contraindication of the use of an oropharyngeal airway? Bag mask ventilation Conscious patient Pediatric patient Absent gag reflexConscious patientWhich of the following patients can NPAs be used in? Unconscious Patient with nasal trauma Conscious SemiconsciousEverything but nasal traumaWhat is the first line treatment for bradycardia?Give atropine 1mg IV may repeat for a total does of 3mg IV If this is ineffective provide transcutaneous pacing and/or dopamine 5 to 20 mcg/kg per minute or epinephrine 2 to 10 mcg/minYou are treating a patient with a heart rate of 186/min. Which symptom (if present) suggest unstable tachycardia? SOB Weakness Hypotension FatigueHypotensionWhat is the first line treatment for unstable tachycardia? Lidocaine Cardioversion Amiodarone AdenosineCardioversionWhat is the upper heart rate limit for a patient with sinus tachycardia? 200/min 130 180 150130What is the lower heart rate limit for a patient with sinus tachycardia?100What is the recommended initial therapy for a patient with stable narrow-complex tachycardia, after establishing an IV and acquiring a 12-lead ecg? Adenosine B-blockers Cardioversion Vagal maneuversVagal maneuversIf a patient with stable ventricular tachycardia does not response to vagal maneuvers, what drug and dose regimen is to be given?Give Adenosine 6mg over 1 second followed by a flush in a large vein and elevate arm quickly after If they don't response in 1-2 minutes, Administer 12 mg IV followed by a flush and elevate arm quickly