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Nurs 3000 - content after midterm

Terms in this set (85)

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a client whose rhythm is regular. From these data, which of the following rates should the nurse calculate as the client's heart rate?
A: 60 beats/minute
B: 75 beats/minute
C: 100 beats/minute A
D: 150 beats/minute

A: C- Since each small block on the ECG paper represents 0.04 seconds, 1 500 of these blocks represents 1 minute. By dividing the number of small blocks (15 in this case) into 1 500, the nurse can calculate the heart rate in a client whose rhythm is regular (in this case, 100).
Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG?
A: The length of time it takes to depolarize the atrium
B: The length of time it takes for the atria to depolarize and repolarize
C: The length of time for the electrical impulse to travel from the SA node to the Purkinje fibres
D: The length of time it takes for the electrical impulse to travel from the SA node to the AV node

A: C - The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibres in order for synchronous atrial and ventricular contraction to occur. The P wave represents atrial contraction and the R wave is part of the QRS complex that represents ventricular contraction. Therefore, when measuring the time from the beginning of the P wave to the beginning of the QRS (PR interval), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibres.
The nurse obtains a 6-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; QRS 0.04 second; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following descriptions is a correct interpretation of this rhythm strip?
Sinus dysrhythmias
Third-degree heart block
Wenckebach phenomenon
Premature ventricular contractions

A: B - Third-degree heart block represents a loss of communication between the atrium and ventricles. This is depicted on the rhythm strip as no relationship between the P waves, representing atrial contraction, and QRS complexes, representing ventricular contraction. The atria are beating totally on their own at 70 beats/minute, whereas the ventricles are pacing themselves at 40 beats/minute.
The nurse is caring for a client who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time?
Reinforcing the pressure dressing as needed
Encouraging range-of-motion exercises of the involved arm
Assessing the incision for any redness, swelling, or discharge
Applying wet-to-dry dressings every 4 hours to the insertion site

A: C - After pacemaker insertion, it is important for the client to limit activity of the involved arm to minimize pacemaker lead displacement. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the nurse to observe for signs of infection by assessing for any redness, swelling, or discharge from the incision site.
The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 second (narrow), but they occur irregularly with a rate of 120 beats/minute. Which of the following rhythms should the nurse identify from this data?
Sinus tachycardia
Atrial fibrillation
Ventricular fibrillation
Ventricular tachycardia

A: B - Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating.
A client has sought care following a syncopal episode of unknown etiology. Which of the following nursing actions should the nurse prioritize in the client's subsequent diagnostic workup?
Preparing to assist with a head-upright tilt-table test
Assessing the client's knowledge of pacemakers
Preparing an intravenous dose of a β-adrenergic blocker
Teaching the client about the role of antiplatelet aggregators

A: A - A head-upright tilt-table test is a common component of the diagnostic workup following episodes of syncope. IV α-blockers are not indicated, and addressing pacemakers is premature and inappropriate at this stage of diagnosis. Client education surrounding antiplatelet aggregators is not directly relevant to the client's syncope.
For which of the following dysrhythmias is defibrillation primarily indicated?
Ventricular fibrilla tion
Third-degree AV block
Uncontrolled atrial fibrillation
Ventricular tachycardia with a pulse

A: A - Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the client is stable). Otherwise, synchronized cardioversion is used (as long as the client has a pulse). Pacemakers are the treatment of choice for third-degree heart block.
The nurse is caring for a client in asystole. Which of the following drug treatments is the client most likely to receive?
Atropine and epinephrine
Lidocaine and amiodarone
Digoxin and procainamide
α-Adrenergic blockers and dopamine

A: A - Normally the client in asystole cannot be successfully resuscitated. However, administration of atropine and epinephrine may prompt the return of depolarization and ventricular contraction.
The nurse is caring for a client with ventricular tachycardia. Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)?
Unmeasurable rate and rhythm
Rate 150 beats/minute; inverted P wave
Rate 200 beats/minute; P wave not visible
Rate 125 beats/minute; normal QRS complex

A: C - Ventricular tachycardia (VT) is associated with a rate of 150-250 beats/minute; the P wave is not normally visible. P wave inversion and a normal QRS complex are not associated with VT. Rate and rhythm are not measurable in ventricular fibrillation.
The nurse is admitting a client and notes clubbing of the client's fingers. Based on this finding, which of the following disease processes should the nurse assess in the client?
Endocarditis
Acute renal failure
Myocardial infarction
Chronic thrombo-phlebitis
A: A- Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and prolonged oxygen deficiency.
The nurse is admitting a client with pericarditis. Which of the following symptoms should the nurse assess for in the client?
Pulsus paradoxus
Prolonged PR intervals
Widened pulse pressure
Clubbing of the fingers
A: A - The nurse will assess for pulsus paradoxus. Pulsus paradoxus >10 mm Hg is a sign of cardiac tamponade, which can result from pericarditis. Cardiac tamponade is an emergency situation that should be assessed at least every 4 hours in a client with pericarditis.
The nurse is conducting a complete physical assessment on a client admitted with infective endocarditis. Which of the following findings is significant?
Respiratory rate of 18 and heart rate of 90
Regurgitant murmur at the mitral valve area
Heart rate of 94 and capillary refill time of 2 seconds
Point of maximal impulse palpable in fourth intercostal space
A: B - A regurgitant murmur would indicate valvular disease, which can be a complication of endocarditis. All the other findings are within normal limits.
The nurse is caring for a client who has recently recovered from rheumatic fever. Which of the following nursing actions is priority to include in the client teaching plan?
How to manage physical activity
The need for ongoing anticoagulation therapy
The need for continuous antibiotic prophylaxis
The need to maintain standard infection-control procedures
A: C- Clients with a history of rheumatic fever frequently require ongoing antibiotic prophylaxis, an intervention that necessitates education. This consideration is more important than activity management in preventing recurrence. Anticoagulation and standard precautions are not indicated in this client population.
The nurse is caring for a client with infective endocarditis. Which of the following vascular manifestations should the nurse assess for based on this diagnosis? (Select all that apply.)
Osler's nodes
Janeway's lesions
Splinter hemorrhages
Subcutaneous nodules
Erythema marginatum lesions
A: A,B,C - Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.
The nurse is caring for a client with a diagnosis of deep venous thrombosis (DVT). The client has an order to receive 30 mg enoxaparin. Which of the following injection sites should the nurse use to administer this medication safely?
Buttock, upper outer quadrant
Abdomen, anterior-lateral aspect
Back of the arm, 5 cm away from a mole
Anterolateral thigh, with no scar tissue nearby
A: B - Enoxaparin (Lovenox) is a low-molecular-weight heparin (LMWH) that is given as a subcutaneous injection. The preferred injection site for this medication is the right and left anterolateral abdominal wall. All subcutaneous injections should be given away from scars, lesions, or moles.
The nurse is preparing to administer a scheduled dose of heparin sodium subcutaneously to a client. The nurse should do which of the following to administer this medication correctly?
Remove the air bubble in the prefilled syringe.
Aspirate before injection to prevent intravenous administration.
Rub the injection site after administration to enhance absorption.
Pinch the skin between the thumb and forefinger before inserting the needle.
A: D The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue but release before removing the needle. The nurse should neither aspirate nor rub the site after injection.
The nurse is admitting preoperative client with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the client has been taking warfarin on a daily basis. Based on this history and the client's admission diagnosis, the nurse should prepare to administer which of the following medications?
Vitamin K
Vitamin B12
Heparin sodium
Protamine sulphate
A: A - Warfarin is an anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin.
The nurse is caring for a client who has been receiving warfarin as treatment for atrial fibrillation. Because warfarin has been discontinued before surgery, the nurse should diligently assess the client for which of the following complications early in the postoperative period?
Decreased cardiac output
Increased blood pressure
Cerebral or pulmonary emboli
Excessive bleeding from incision or IV sites
A: C - Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more detach from the atrial wall, they could travel as cerebral emboli from the left atrium, or pulmonary emboli from the right atrium.
The nurse is reviewing the laboratory test results for a client whose warfarin therapy was terminated during the preoperative period. The nurse concludes that the client is in the most stable condition for surgery after noting which of the following international normalized ratio (INR) results?
2.7
1.0
3.4
1.8
A: D - The therapeutic range for international normalized ratio (INR) results is 2.0-3.0 for many clinical diagnoses and 0.75-1.25 is the normal value with no clinical diagnoses. The larger the number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.
The nurse would determine that a postoperative client is not receiving the beneficial effects of enoxaparin after noting which of the following during a routine shift assessment?
Generalized weakness and fatigue
Crackles bilaterally in the lung bases
Pain and swelling in the lower extremity
Abdominal pain with decreased bowel sounds
A: C - Enoxaparin is a low-molecular-weight heparin (LMWH) used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of a DVT and therefore may signal ineffective medication therapy.
The nurse is caring for a client with a recent history of deep vein thrombosis (DVT). The client now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this client before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which of the following values?
2.2
1.0
1.6
1.2
A: A - Vitamin K is the antidote to warfarin which the client has most likely been taking until admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.
A postoperative client asks the nurse why the physician ordered daily administration of enoxaparin. Which of the following responses by the nurse is best?
"This medication will help prevent breathing problems after surgery, such as pneumonia."
"This medication will help lower your blood pressure to a safer level, which is very important after surgery."
"This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."
"This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
A:C - Enoxaparin (Lovenox) is an anticoagulant used to prevent DVTs postoperatively. All other explanations or choices do not describe the action or purpose of enoxaparin.
The nurse is caring for a preoperative client who has a prescription for vitamin K by subcutaneous injection. The nurse should verify that which of the following laboratory studies is abnormal before administering the dose?
Hematocrit (Hct)
Hemoglobin (Hb)
Prothrombin time (PT)
Partial thromboplastin time (PTT)
A: C- Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrate the need for this medication.
The nurse is caring for a newly admitted client with vascular insufficiency. The client has a new order for enoxaparin 30 mg subcutaneously. Which of the following actions should the nurse do to correctly administer this medication?
Spread the skin before inserting the needle.
Leave the air bubble in the prefilled syringe.
Use the back of the arm as the preferred site.
Sit the client at a 30-degree angle before administration.
A: B - The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.
Which of the following interventions in the care of a client with a diagnosis of chronic venous insufficiency (CVI) is priority?
Application of topical antibiotics to venous ulcers
Maintaining the client's legs in a dependent position
Administration of oral and subcutaneous anticoagulants (or both)
Teaching the client the correct use of compression stockings
A: D - Chronic venous insufficiency (CVI) requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The client should avoid prolonged positioning with the limb in a dependent position.
A client with varicose veins has been prescribed compression stockings. Which of the following statements is accurate when teaching the client?
"As much as possible, try to keep your stockings on 24 hours a day."
"While you're still lying in bed in the morning, put on your stockings."
"Dangle your feet at your bedside for 5 minutes before putting on your stockings."
"Your stockings will be most effective if you can remove them for a few minutes several times a day."
A: B - The client with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.
The nurse is assessing a client's peripheral intravenous site and notes that phlebitis has developed over the past several hours. Which of the following actions should the nurse implement first?
Remove the client's IV catheter.
Apply an ice pack to the affected area.
Decrease the IV rate to 20-30 mL/hour.
Administer prophylactic anticoagulants.
A: A - The priority intervention for superficial phlebitis is removal of the offending IV catheter; decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.
The nurse is caring for a client admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 38.6°C (101.5°F), a productive cough with yellow sputum, and a respiratory rate of 20 breaths/minute. Which of the following nursing diagnoses is most appropriate based upon this assessment?
Hyperthermia related to infectious illness
Ineffective thermoregulation related to chilling
Ineffective breathing pattern related to pneumonia
Ineffective airway clearance related to thick secretions
A: A - Because the client has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and the client's breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the client is expectorating sputum.
Which of the following physical assessment findings in a client with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?
Basilar crackles
Respiratory rate of 28
Oxygen saturation of 85%
Presence of greenish sputum
A: A - The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the client is retaining secretions.
Which of the following clinical manifestations should the nurse expect to find during assessment of a client admitted with pneumococcal pneumonia?
Hyper-resonance on percussion
Vesicular breath sounds in all lobes
Increased tactile fremitus on palpation
Fine crackles in all lobes on auscultation
A: D - A typical physical examination finding for a client with pneumonia is increased tactile fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following is the priority nursing intervention in helping a client expectorate thick lung secretions?
Humidify the oxygen as able
Administer cough suppressant q4hr
Teach client to splint the affected area
Increase fluid intake to 3 L/day if tolerated
A: A - Although several interventions may help the client expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the client can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the client to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.
The nurse is providing discharge teaching to an older-adult client with COPD and pneumonia. Which of the following vaccines should the nurse recommend that this client receive?
Staphylococcus aureus
Haemophilus influenzae
Pneumococcal
Bacille Calmette-Guérin (BCG)
...
The nurse is providing discharge teaching to a client that was hospitalized with pneumonia. Which of the following client statements about measures to prevent a relapse indicates that the teaching has been effective?
"I will seek immediate medical treatment for any upper respiratory infections."
"I will increase my food intake to 2 400 calories a day to keep my immune system well."
"I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
"I must use home oxygen therapy for three months and then will have a chest x-ray to re-evaluate."
A: C - The pneumococcal vaccine is important for clients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse is admitting a client to the medical unit with a diagnosis of pneumonia. Which of the following prescriptions should the nurse verify has been completed before administering a dose of trimethoprim-sulfamethoxazole to the client?
Orthostatic blood pressures
Sputum culture and sensitivity
Pulmonary function evaluation
Serum laboratory studies ordered for the morning
A: B - The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering trimethoprim-sulfamethoxazole. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the client to expectorate sputum, all of the other options will not be affected by the administration of antibiotics.
Which of the following nursing interventions is most appropriate to enhance oxygenation in a client with unilateral malignant lung disease?
Positioning client on right side
Maintaining adequate fluid intake
Positioning client with "good lung down"
Performing postural drainage every 4 hours
A: D - Therapeutic positioning identifies the best position for the client assuring stable oxygenation status. Research indicates that positioning the client with the unaffected lung (good lung) dependent best promotes oxygenation in clients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
The nurse is admitting a client with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this client?
Perform a comprehensive health history with the client to review prior respiratory problems.
Complete a full physical examination to determine the effect of the respiratory distress on other body functions.
Delay any physical assessment of the client and review with the family the client's history of respiratory problems.
Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
A: D - Because the client is having respiratory difficulty, the nurse should complete a focused assessment—ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the client's acute respiratory distress is being managed.
The nurse is planning care for a client with metastatic lung cancer who has a 60-pack-per-year history of cigarette smoking. Which of the following respiratory defences is impaired related to tobacco use?
Cough reflex
Mucociliary clearance
Reflex bronchoconstriction
Ability to filter particles from the air
A: B - Smoking decreases the ciliary action in the tracheo-bronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
The nurse is assisting a client with metastatic lung cancer to ambulate when the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is best for the nurse to implement?
Continue with ambulation since this is a normal response to activity.
Obtain a prescription for arterial blood gas determinations to verify the oxygen saturation.
Obtain a prescription for supplemental oxygen to be used during ambulation and other activity.
Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
A: C - An oxygen saturation level that drops below 90% with activity indicates that the client is not tolerating the exercise and needs to use supplemental oxygen.
The nurse is caring for a client who underwent a left total knee arthroplasty. On the third postoperative day, the client has symptoms of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 36.9°C (98.4°F), blood pressure 130/88 mm Hg, respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the following etiologies should the nurse first suspect related to these findings?
New onset of angina pectoris
Septic embolus from the knee joint
Pulmonary embolus from deep vein thrombosis
Pleural effusion related to positioning in the operating room
A: C - The client presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
The nurse is caring for a client who underwent a left total knee arthroplasty. On the third postoperative day, the client has symptoms of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 36.9°C (98.4°F), blood pressure 130/88 mm Hg, respirations 36 breaths/minute, and oxygen saturation 91% in room air. Which of the following actions should the nurse take first?
Notify the health care provider.
Administer a nitroglycerine tablet sublingually.
Conduct a thorough assessment of the chest pain.
Sit the client up in bed as tolerated and apply oxygen.
A: D - The client's clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the client. For this reason, the nurse should sit the client up as tolerated and apply oxygen before notifying the physician.
The nurse is caring for a client with pneumonia. Which of the following actions should the nurse include in the plan of care to promote airway clearance? (Select all that apply.)
Maintain adequate fluid intake
Splint the chest when coughing
Maintain a high Fowler's position
Maintain a semi-Fowler's position
Instruct client to cough at end of exhalation
A: A,B.C,E - The nurse should instruct the client to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. Coughing at the end of exhalation promotes a more effective cough. The client should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
The nurse is admitting a client who has diagnosed with non-small cell carcinoma of the lung. Which of the following risk factors should the nurse assess in the client related to this type of cancer? (Select all that apply.)
Asbestos exposure
Cigarette smoking
Exposure to uranium
Chronic interstitial fibrosis
Geographic area in which he was born
A: A,B,C - Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. The geographic area where the client was born is not a risk factor for this type of cancer.
The nurse is admitting a client with a diagnosis of pulmonary embolism. Which of the following risk factors should the nurse assess for in the client? (Select all that apply.)
Obesity
Pneumonia
Hypertension
Cigarette smoking
Prolonged air travel
A: A,C,D,E - Research has demonstrated an increased risk of pulmonary embolism in women associated with obesity, heavy cigarette smoking, and hypertension. Other risk factors include immobilization, surgery within the last 3 months, stroke, history of deep vein thrombosis (DVT), malignancy, and recent prolonged air travel.
The nurse is completing an admission history for an older-adult client who has osteoarthritis admitted for knee arthroplasty and the nurse asks about the client's perception of the reason for admission. Which of the following client responses should the nurse anticipate related to this question?
Recent knee trauma
Debilitating joint pain
Repeated knee infections
Onset of "frozen" knee joint
A: B - The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy.
The nurse is caring for a client with osteoarthritis who is about to undergo left total knee arthroplasty (TKA). The nurse assesses the client carefully to be sure that there is no evidence of which of the following symptoms in the preoperative period?
Pain
Left knee stiffness
Left knee infection
Left knee instability
A: C - It is critical that the client be free of infection before a total knee arthroplasty (TKA). An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the client for signs of infection, such as redness, swelling, fever, and elevated white blood cell count.
The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for an older-adult client following a left total knee replacement. Which of the following actions would be an appropriate nursing intervention for this client?
Promote vitamin D and calcium intake in the diet.
Provide passive range of motion to all of the joints q4h.
Encourage isometric quadriceps-setting exercises at least qid.
Keep the left leg in extension and abduction to prevent contractures.
A: C - Great emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery.
The nurse is caring for an older-adult client who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects which of the following interventions will be included in the care of the affected leg?
Progressive leg exercises to obtain 90-degree flexion
Early ambulation with full weight bearing on the left leg
Bed rest for three days with the left leg immobilized in extension
Immobilization of the left knee in 30-degree flexion for two weeks to prevent dislocation
A: A -The client is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the client requires good pain management and often the use of a continuous passive motion (CPM) machine.
The nurse is caring for an older-adult client who underwent left total knee arthroplasty and has a new health care provider order to be "up in chair today before noon." Which of the following actions would the nurse implement to protect the knee joint while carrying out the order?
Administer a dose of prescribed analgesic before completing the order.
Ask the physiotherapist for a walker to limit weight bearing while getting out of bed.
Keep the continuous passive motion machine in place while lifting the client from bed to chair.
Put on a knee immobilizer before moving the client out of bed and keep the surgical leg elevated while sitting.
A: D - The nurse should apply a knee immobilizer for stability before assisting the client to get out of bed. This is a standard measure to protect the knee during movement following surgery.
The nurse is completing discharge teaching with an older-adult client who underwent right total hip arthroplasty (THA). Which of the following client statements indicates a need for further instruction?
Avoid crossing his legs.
Use a toilet elevator on toilet seat.
Notify future caregivers about the prosthesis.
Maintain hip in adduction and internal rotation.
A: D - The client should not cross legs, force hip into adduction, or force hip into internal rotation.
The nurse is providing discharge teaching for a client with metastatic lung cancer who was admitted with a bowel impaction. Which of the following instructions is most helpful to prevent further episodes of constipation?
Maintain a high intake of fluid and fibre in the diet.
Reduce intake of medications causing constipation.
Eat several small meals per day to maintain bowel motility.
Sit upright during meals to increase bowel motility by gravity.
A: A - Increased fluid intake and a high-fibre diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fibre provide bulk that in turn increases peristalsis and bowel motility.
The nurse should administer a prn dose of magnesium hydroxide after noting which of the following findings while reviewing a client's medical record?
Abdominal pain and bloating
No bowel movement for 3 days
A decrease in appetite by 50% over 24 hours
Muscle tremors and other signs of hypomagnesemia
A: B - Magnesium hydroxide (milk of magnesia) is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the client who has not had a bowel movement for 3 days.
The nurse is preparing to administer a dose of bisacodyl. In explaining the medication to the client, the nurse would state that it acts in which of the following ways?
Increases bulk in the stool
Lubricates the intestinal tract to soften feces
Increases fluid retention in the intestinal tract
Increases peristalsis by stimulating nerves in the colon wall
A: D - Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms.
The nurse is preparing to administer a scheduled dose of docusate sodium when the client indicates an episode of loose stool and does not want to take the medication. Which of the following is the best action by the nurse?
Write an incident report about this untoward event.
Attempt to have the family convince the client to take the ordered dose.
Withhold the medication at this time and try to administer it later in the day.
Chart the dose as not given on the medical record and explain in the nursing progress notes.
A: D - Whenever a client refuses medication, the dose should be charted as not given. An explanation of the reason should then be documented in the nursing progress notes. In this instance, the refusal indicates good judgement by the client.
A client is prescribed "Colace 100 mg PO." The client asks to take the medication in liquid form, and the nurse obtains an order for the interchange. Available is a syrup that contains 150 mg/15 mL. How many millilitres does the nurse administer?
3 mL
5 mL
10 mL
12 mL
A: C- The concentration of the syrup is 150 mg/15 mL. 100 mg divided by 150 mg multiplied by 15 mL = 10 mL.
The nurse should instruct the client to do which of the following to best enhance the effectiveness of a daily dose of docusate sodium?
Take a dose of mineral oil at the same time.
Add extra salt to food on at least one meal tray.
Ensure dietary intake of 10 g of fibre each day.
Take each dose with a full glass of water or other liquid.
A: D - Docusate sodium (Colace) lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage, and must be taken with adequate fluids. The client should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fibre intake should be a minimum of 20 g daily to prevent constipation.
Which of the following cathartic agents in a client with renal insufficiency should the nurse question?
Bisacodyl
Senna
Cascara sagrada
Magnesium hydroxide
A: D - Magnesium hydroxide (milk of magnesia) may cause hypermagnesemia in clients with renal insufficiency. The nurse should question this order with the health care provider before administration.
A client who is administering a bisacodyl suppository asks the nurse how long it will take to work. The nurse replies that the client will probably need to use the bedpan or commode within which of the following time frames after administration?
2-5 minutes
15-60 minutes
2-4 hours
6-8 hours
A: B - Bisacodyl suppositories usually are effective within 15-60 minutes of administration, so the nurse should plan accordingly to assist the client to use the bedpan or commode.
The nurse is caring for a client in the emergency department with symptoms of acute abdominal pain, nausea, and vomiting. When the nurse palpates the client's left lower abdominal quadrant, the client has pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis?
Rovsing's sign
Referred pain
Chvostek's sign
Rebound tenderness
A: A - In clients with suspected appendicitis, Rovsing's sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant.
The nurse is caring for an admitted client with abdominal pain, nausea, and vomiting. The client has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which of the following types of bowel sounds that is consistent with the client's clinical picture?
Low pitched and rumbling above the area of obstruction
High pitched and hypoactive below the area of obstruction
Low pitched and hyperactive below the area of obstruction
High pitched and hyperactive above the area of obstruction
A: D - Early in intestinal obstruction, the client's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
The nurse is planning care for a client with an abdominal mass and suspected bowel obstruction. Which of the following factors in the client's history increases the client's risk for colorectal cancer?
Osteoarthritis
History of rectal polyps
History of lactose intolerance
Use of herbs as dietary supplements
A: B- A history of rectal polyps places this client at risk for colorectal cancer. This tissue can degenerate over time and become malignant. The other factors identified do not pose additional risk to the client.
The nurse is preparing to insert a nasogastric tube into a client with an abdominal mass and suspected bowel obstruction. The client asks the nurse why this procedure is necessary. Which of the following responses is best?
"The tube will help to drain the stomach contents and prevent further vomiting."
"The tube will push past the area that is blocked, and thus help to stop the vomiting."
"The tube is just a standard procedure before many types of surgery to the abdomen."
"The tube will let us measure your stomach contents so that we can plan what type of IV fluid replacement would be best."
A: A - The nasogastric tube is used to decompress the stomach by draining stomach contents, and thereby prevent further vomiting.
The nurse is caring for a client with a suspected bowel obstruction who has had a nasogastric tube inserted at 0400 hours. The nurse shares in the morning report that the day shift (0700-1500 hours) staff should check the tube for patency at which of the following times?
0700, 1000, and 1300 hours
0800 and 1200 hours
0900 and 1500 hours
0900, 1200, and 1500 hours
A: B - A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 0400 hours, it would be due to be checked at 0800 hours and 1200 hours.
The nurse who inserted a nasogastric tube for a client with suspected bowel obstruction should write which of the following priority nursing diagnoses on the client's problem list?
Anxiety related to nasogastric tube placement
Abdominal pain related to nasogastric tube placement
Risk for deficient knowledge related to nasogastric tube placement
Altered oral mucous membrane related to nasogastric tube placement
A: D - With nasogastric tube placement, the client is likely to breathe through the mouth and may experience irritation in the affected nares. For this reason, the nurse should plan preventive measures based on this nursing diagnosis.
A colectomy is scheduled for a client with an abdominal mass, possible bowel obstruction, and a history of rectal polyps. The nurse should plan to include which of the following prescribed measures in the preoperative preparation of this client?
Instruction on irrigating a colostomy
Administration of an oral osmotic lavage
A high-fibre diet the day before surgery
Administration of IV antibiotics for bowel preparation
A: B - Bowel preparation before surgery includes orally administered osmotic lavages (e.g., GoLYTELY). This has shortened the classic 72-hour preparation with clear liquids, cathartics, and enemas.
Which of the following information should be the highest priority information to include in preoperative teaching for a client scheduled for a colectomy?
How to care for the wound?
How to deep-breathe and cough?
The location and care of drains after surgery
What medications will be used during surgery?
A: B - Because anaesthesia, an abdominal incision, and pain can impair the client's respiratory status in the postoperative period, it is of high priority to teach the client to cough and deep-breathe. Otherwise, the client could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge.
The nurse asks a client scheduled for colectomy to sign the operative consent as directed in the health care provider's preoperative orders. The client states that the health care provider has not really explained well what is involved in the surgical procedure. Which of the following is the best action by the nurse?
Ask family members whether they have discussed the surgical procedure with the health care provider.
Have the client sign the form and state that the health care provider will visit to explain the procedure before surgery.
Explain the planned surgical procedure as well as possible, and have the client sign the consent form.
Delay the client's signature on the consent and notify the health care provider about the conversation with the client.
A: D- The client should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the client. The nurse should notify the health care provider, who has the responsibility for obtaining consent.
Two days following a colectomy for an abdominal mass, a client reports gas pains and abdominal distension. The nurse plans care for the client based on the knowledge that the symptoms occur as a result of which of the following?
Impaired peristalsis
Irritation of the bowel
Nasogastric suctioning
Anastomosis site inflammation
A: A - Until peristalsis returns to normal following anaesthesia, the client may experience slowed gastrointestinal motility leading to gas pains and abdominal distension.
The nurse is caring for a client following bowel resection and has a nasogastric tube to suction, but symptoms of nausea and abdominal distension. The nurse irrigates the tube prn as prescribed, but the irrigating fluid does not return. Which of the following actions is priority?
Notify the health care provider.
Auscultate for bowel sounds.
Reposition the tube and check for placement.
Remove the tube and replace it with a new one.
A: C -The tube may be resting against the stomach wall. The first action by the nurse, since this is intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement.
The nurse is caring for a postoperative client with a colostomy. The nurse is preparing to administer a dose of famotidine when the client asks why the medication was prescribed since the client does not have a history of heartburn or gastro-esophageal reflux disease (GERD). Which of the following statements is the best response by the nurse?
"This will prevent air from accumulating in the stomach, causing gas pains."
"This will prevent the heartburn that occurs as a adverse effect of general anaesthesia."
"The stress of surgery is likely to cause stomach bleeding if you do not receive it."
"This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again.
A: D- Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the client is not eating a regular diet after surgery.
The nurse is caring for a client admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol misuse who has a serum amylase level of 280 units/L and a serum lipase level of 310 units/L. To which of the following diagnoses does the nurse attribute these findings?
Malnutrition
Osteomyelitis
Alcohol misuse
Diabetes mellitus
A: C- The client with alcohol misuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 100-200 units/L) and serum lipase (normal <160 units/L) levels as shown.
The health care provider prescribes lactulose for a client with hepatic encephalopathy. Which of the following assessment parameters should the nurse monitor for effectiveness of this medication?
Relief of constipation
Relief of abdominal pain
Decreased liver enzymes
Decreased ammonia levels
A: A - Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.
The family of a client newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which of the following responses by the nurse is most appropriate?
"The hepatitis vaccine will provide immunity from this exposure and future exposures."
"I am afraid there is nothing you can do since the client was infectious before admission."
"You will need to be tested first to make sure you don't have the virus before we can treat you."
"An injection of immune globulin will need to be given to prevent or minimize the effects from this exposure."
A: C - Immune globulin provides temporary (6-8 weeks) passive immunity and is effective for preventing hepatitis A if given within 1-2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is used only for pre-exposure prophylaxis.
The nurse is planning care for a client with cirrhosis. Which of the following nursing diagnoses is priority?
Imbalanced nutrition: less than body requirements
Impaired skin integrity related to edema, ascites, and pruritus
Excess fluid volume related to portal hypertension and hyperaldosteronism
Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
A: D - Although all of these nursing diagnoses are appropriate and important in the care of a client with cirrhosis, airway and breathing are always the highest priorities.
The nurse is caring for a client with liver disease and recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which of the following nursing interventions would be appropriate to achieve this outcome? (Select all that apply.)
Use smallest gauge possible when giving injections or drawing blood.
Teach client to avoid straining at stool, vigorous blowing of nose, and coughing.
Advise client to use soft-bristle toothbrush and avoid ingestion of irritating food.
Apply gentle pressure for the shortest possible time period after performing venipuncture.
Instruct client to avoid Aspirin and NSAIDs to prevent hemorrhage when varices are present.
A: A,B,C,D - Using the smallest gauge for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding.
The nurse is caring for a client with a biliary obstruction. Which of the following vitamin supplements should the nurse anticipate administering? (Select all that apply.)
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Vitamin B
A: A,B,E,K - Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat soluble and thus would need to be supplemented in a client with biliary obstruction.
The nurse is teaching health promotion to a variety of female clients in a community centre and a client asks when a female should begin having a Pap smear. Which of the following responses by the nurse is best?
"Every year, beginning at age 30."
"Every three years, beginning at age 18."
"Every three years, beginning three years after first intercourse or at least by age 21."
"Every year, beginning at the onset of menarche and continuing until menopause."
A: C - Sexually active women between the ages of 21 and 69 should have a Papanicolaou test (Pap smear) every one to three years, depending on the screening guidelines in their province or territory and their previous test results. Women 69 years or older may stop having Pap tests following two or three previously normal (negative) Pap results.
The nurse is teaching a client who has diagnosed with pelvic inflammatory disease (PID). Which of the following information should the nurse emphasize?
The importance of contraception
Signs and symptoms of infection
The importance of maintaining hygiene
Benefits of hormone replacement therapy (HRT)
A: B - Pelvic inflammatory disease (PID) frequently progresses to serious infection of the reproductive structures. The diagnosis does not present a particular need for contraception or specific hygiene measures. Hormone replacement therapy (HRT) is not used to treat PID.
The nurse is caring for a client who is one day postoperative from an abdominal hysterectomy. Which of the following interventions should the nurse perform in order to prevent deep venous thrombosis (DVT)?
Place the client in a high Fowler's position.
Provide pillows to place under the client's knees.
Encourage the client to change positions frequently.
Teach the client deep-breathing and coughing exercises.
A: C - The high Fowler's position and pressure under the knees should be avoided in order to prevent deep venous thrombosis (DVT). Deep breathing and coughing are therapeutic exercises, but do not directly address the risk of DVT. The client should be encouraged to change positions frequently and ambulate to prevent venous stasis.
Which of the following information should be provided to a client postoperative a surgical repair of a fistula?
Douche daily to prevent postoperative infection.
Remove and cleanse her pessary on a daily basis.
Resume normal activity to prevent adhesion formation.
Ensure that she does not place stress on the repaired area.
A: D - Following surgical repair of a fistula, the client should be encouraged to avoid placing stress on the repaired region. Normal activity is not commonly resumed until significant healing has occurred. Douching is contraindicated, and pessaries are used to treat prolapses, not fistulas.
The nurse is providing education to a group of clients who are perimenopausal. Which of the following herbs and/or supplements would the nurse include in a discussion regarding effective alternative therapies? (Select all that apply.)
Soy
Garlic
Gingko
Vitamin A
Black cohosh
A: A,E - There is good scientific evidence that soy is useful in decreasing menopausal hot flashes and that black cohosh is safe to use for up to 6 months to decrease menopausal symptoms.
The nurse is admitting a male client for a total knee replacement who states during the health history interview no problems with urinary elimination except that the "stream is less than it used to be." The nurse would give the client anticipatory guidance that which of the following conditions is likely to be developing?
A tumour of the prostate
Benign prostatic hyperplasia (BPH)
Bladder atony because of age
Age-related altered innervation of the bladder
A: B- Benign prostatic hyperplasia (BPH) is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80.
To accurately monitor progression of the symptom of decreased urinary stream, the nurse should encourage the client to have which of the following primary screening measures done on a regular basis?
Uroflowmetry
Transrectal ultrasound
Digital rectal examination (DRE)
Prostate-specific antigen (PSA) monitoring
A: B - Digital rectal examination (DRE) is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age
The nurse is caring for a client who is one day postoperative following a transurethral resection of the prostate (TURP). Which of the following events should the nurse prioritize for intervention?
The client required two tablets of Tylenol No. 3 twice overnight.
The client complains of fatigue and claims to have minimal appetite.
The client's continuous bladder irrigation (CBI) is infusing, but output has decreased.
The client has expressed anxiety about his planned discharge home the following day.
A: A - A decrease or cessation of output in a client with continuous bladder irrigation (CBI) requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the client or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the client's CBI.
The nurse is preparing a client with a diagnosis of benign prostatic hyperplasia (BPH) for surgery. Which of the following goals is the primary goal of this intervention?
Resumption of normal urinary drainage
Maintenance of normal sexual functioning
Prevention of acute or chronic renal failure
Prevention of fluid and electrolyte imbalances
A: C - The most significant signs and symptoms of benign prostatic hyperplasia (BPH) relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. Surgery is performed primarily to resolve these problems. Fluid imbalances, problems with sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.
Which of the following tasks can the nurse delegate to an unregulated care provider (UCP) in the care of a client who has recently undergone prostatectomy?
Assessing the client's incision
Irrigating the client's Foley catheter
Assessing the client's pain and selecting analgesia
Performing cleansing of the meatus and perineal region
A: D - Performing perineal care is an appropriate task for delegation. Selecting analgesia, irrigating the client's catheter, and assessing his incision are not appropriate for skills or tasks for unlicensed personnel.
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