Question and Answer Key GI/Neuro Med Surg. With Rationale 2021

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Question and Answer Key GI/Neuro Med Surg. With Rationale 2021 | 1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’... s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances. 2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.” Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas. 3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness. 4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia. C. Increased muscle tone Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased muscle tone. D. Oriented to time, person, place Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not orientation to time, person, and place. 5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is A. bradycardia. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. B. ipsilateral pupil dilation. Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure displaces the brain against the optic nerve, but pupil dilation is not an early sign of increased ICP. C. widening pulse pressure. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. D. lethargy. Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy. 6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed. B. Supplements via nasogastric tube Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed. C. Initiation of total parenteral nutrition Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will not likely be prescribed. D. Soft residue diet Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing solids; therefore, this nutritional therapy will not likely be prescribed. 7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse? A. "Incorporate nonverbal cues in the conversation." Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language. B. "Ask multiple choice questions as part of the conversation." Rationale: Simple questions requiring yes/no responses are better understood by the client. C. "Use a higher-pitched tone of voice when speaking." Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing impairment. D. "Use simple child-like statements when speaking." Rationale: It is important to respect the client and use age-appropriate communication. 8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of the following outcomes should the nurse expect from this client’s medication therapy? A. Increased sodium excretion Rationale: The primary action of spironolactone is to increase sodium excretion in the urines. B. Decreased urinary output Rationale: Spironolactone is a diuretic, thus it should increase urine output. C. Increased potassium excretion Rationale: Spironolactone is potassium-sparing. D. Decreased chloride excretion Rationale: Spironolactone promotes the excretion of chloride in the urine. 9. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration Rationale: Dehydration is not considered a complication of the hypothermia blanket therapy. B. Seizures Rationale: Seizures are not considered a complication of the hypothermia blanket therapy. C. Burns Rationale: Burns are associated with the improper use of heating pads, not a hypothermia blanket. D. Shivering Rationale: The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. 10. An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examination, which of following is the most reliable indicator of cerebral status? A. Pupil response Rationale: The nurse should include pupil response as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. B. Deep tendon reflexes Rationale: The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. C. Muscle strength Rationale: The nurse should include muscle strength as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. D. Level of consciousness Rationale: The nurse should examine the client’s level of consciousness as the most reliable indicator of cerebral status. 11. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy- induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa Rationale: Placenta previa occurs with painless vaginal bleeding. B. Prolapsed cord Rationale: With a prolapsed umbilical cord, there is no bleeding or pain. There may be changes in the fetal heart tracing, and the cord might also become visible. C. Ruptured ovarian cysts Rationale: A rupture of an ovarian cyst can cause sudden pelvic pain, but it does not commonly cause vaginal bleeding. D. Abruptio placentae Rationale: The cardinal signs and symptoms of abruptio placentae include a rigid board-like abdomen, severe pain, and heavy vaginal bleeding. 12. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. Rationale: The first action to take if the client's arm appears to be swollen is to measure the arm and compare it to the circumference of the other arm. If the arm is swollen, it is appropriate to notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site. B. Notify the provider who inserted the PICC line. Rationale: It may be necessary to notify the provider, but this is not the first action the nurse should take. C. Remove the PICC line. Rationale: It may be necessary to remove the PICC line, but this is not the first action the nurse should take. D. Apply a cold pack to the client's upper arm. Rationale: It may be necessary to apply a cold pack to the client's upper arm, but this is not the first action the nurse should take. 13. A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. Rationale: The first action the nurse should take using the nursing process is to assess the client; therefore, assessing the orthostatic blood pressure is the first priority to determine if the client is hypovolemic. B. Explain the procedure for an upper GI series. Rationale: The nurse should explain the procedure for an upper GI series, but this is not the priority. C. Administer pain medication. Rationale: The nurse should administer pain medication as needed, but this is not the priority. D. Test the emesis for blood. Rationale: The nurse should test the emesis for blood if the client vomits, but this is not the priority. 14. A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat- soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin A Rationale: The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K. B. Vitamin B1 Rationale: itamin B1 is not a fat-soluble vitamin. C. Vitamin C Rationale: Vitamin C is not a fat-soluble vitamin. D. Vitamin B12 Rationale: Vitamin B12 is not a fat-soluble vitamin. 15. A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care? A. Monitor respiratory status every 8 hr. Rationale: Monitoring respiratory status is an appropriate intervention, but it is not the next intervention. B. Encourage a side-lying position with knees flexed. Rationale: Encouraging a side-lying position with knees flexed status is an appropriate intervention, but it is not the next intervention. C. Provide frequent oral hygiene. Rationale: Providing frequent oral hygiene status is an appropriate intervention, but it is not the next intervention. D. Maintain NPO status. Rationale: To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis. This is the next intervention to be included in the plan of care. 16. A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A. Establish the ability to communicate effectively. Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. B. Have a regular, formed stool at least every other day. Rationale: This goal is not specific to the client's impairment. C. Learn to control impulsive behavior. Rationale: A client with a right-side lesion is likely to be impulsive. Clients with left-side lesions are typically cautious. D. Improve left-side motor function. Rationale: A client with a left-side lesion will demonstrate hemiplegia of the right side due to the fact that the pyramidal pathway crosses over at the base of the brain. 17. A client comes to the emergency department reporting nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see if the client has acute pancreatitis? A. Decreased WBC Rationale: With acute pancreatitis, WBC is generally elevated. B. Increased serum amylase Rationale: With acute pancreatitis, serum amylase rises within 24 hr of the start of the client’s symptoms. C. Decreased serum lipase Rationale: With acute pancreatitis, serum lipase is generally elevated. D. Increased serum calcium Rationale: Hypocalcemia is common with acute pancreatitis. 18. A nurse is caring for a client who has an acute respiratory illness. The nurse should monitor the client for which of the following manifestations of impending airway obstruction. (Select all that apply.) A. Tachycardia B. Nausea C. Retractions D. Muscle tremors E. Restlessness Rationale: Tachycardia is correct. Increases in pulse and respiratory rates are indications of impending airway obstruction. Nausea is incorrect. Gastrointestinal upset is not an indication of impending airway obstruction. Retractions is correct. Substernal, suprasternal, and intercostal retractions and flaring nares are indications of impending airway obstruction. Muscle tremors is incorrect. Muscle tremors are not an indication of impending airway obstruction. Restlessness is correct. Restlessness is an indication of impending airway obstruction. 19. A nurse is assessing a client who has meningitis and notes when passively flexing the client’s neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig’s sign Rationale: The client who displays the Kernig’s sign is unable to extend the leg completely when the thigh is flexed on the abdomen, which is not the condition manifested but is a common sign of meningitis. B. Nuchal rigidity Rationale: The client who displays nuchal rigidity has a stiff painful neck when the head is flexed, which is not the condition manifested but is a common sign of meningitis. C. Brudzinski sign Rationale: The client was manifesting Brudzinski sign, flexes hips and knees when neck is flexed, a common sign of meningitis. D. Bradykinesia Rationale: The client who displays bradykinesia, slow or no movement of extremities is a sign of Parkinson disease. 20. A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid? A. Noodles Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Noodles are low in fat and are therefore an appropriate food choice for clients with pancreatitis. B. Vegetable soup Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Vegetable soup is low in fat and is therefore an appropriate food choice for clients with pancreatitis. C. Baked fish Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Baked fish is low in fat and is therefore an appropriate food choice for clients with pancreatitis. D. Cheddar cheese Rationale: Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice. 21. A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client’s history? A. Gallstones Rationale: The client’s history may reveal biliary obstruction from a gallstone causing bile to inflame the pancreas. B. Hypolipidemia Rationale: The client’s history may reveal hyperlipidemia, not hypolipidemia, a metabolic disturbance causing an inflamed pancreas. C. COPD Rationale: The client’s history of COPD would not cause pancreatitis. D. Diabetes mellitus Rationale: The client’s history of diabetes mellitus may be a result of pancreatitis, not cause the disorder. 22. A nurse is anticipating the provider’s orders for a client who has a paralytic ileus following an appendectomy. Which of the following are expected nursing actions? A. Administer antacids. Rationale: The nurse should not expect to administer an antacid to the client who has no peristaltic activity, since this may cause further nausea and vomiting. B. Provide bulk-forming agent. Rationale: The nurse should not expect to administer a bulk forming agent to the client who has no peristaltic activity since this may cause further nausea and vomiting. C. Insert nasogastric tube. Rationale: The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus. D. Apply a truss. Rationale: The nurse should not expect to apply a truss to the client who has a paralytic ileus since this is used for hernia. 23. A client comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A. Chvostek’s sign Rationale: Chvostek’s sign is a response of facial twitching when the examiner taps the client’s face over the facial nerve. It indicates hypocalcemia, not blood in the peritoneum. B. Cullen’s sign Rationale: Cullen’s sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy. C. Chadwick’s sign Rationale: Chadwick’s sign is a change in the color of the vagina from pink to purplish. It is a probable finding during pregnancy, not an indication of blood in the peritoneum. D. Goodell’s sign Rationale: Goodell’s sign is a softening of the cervix of the uterus. It is a probable finding during pregnancy, not an indication of blood in the peritoneum. 24. After receiving TPN at 84 ml/hr continuously for five days, a client in a state of confusion pulled out their central line. Prior to notifying the provider, the nurse should start a peripheral IV and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. Rationale: This is not the appropriate intervention for the nurse to take. B. Change the tubing and filter on the TPN. Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to take. C. Hang an infusion 10% dextrose. Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust the client’s blood glucose levels. D. Notify the pharmacy. Rationale: This is not the appropriate intervention for the nurse to take. 25. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. B. Reduce environmental stimuli. Rationale: Reducing environmental stimuli is an appropriate action by the nurse; however, this is not the priority. C. Document intake and output. Rationale: Documenting intake and output is an appropriate action by the nurse; however, this is not the priority. D. Maintain seizure precautions. Rationale: Maintaining seizure precautions is an appropriate action by the nurse; however, this is not the priority. 26. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of A. excessive thirst and urination. Rationale: Excessive thirst and urination are manifestations of hyperglycemia, which is a complication of TPN related to the high proportion of glucose in the infusion. Hyperglycemia would not occur secondary to an interruption in the TPN administration. B. shakiness and diaphoresis. Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. C. fever and chills. Rationale: Fever and chills are manifestations of infection. D. hypertension and crackles. Rationale: Hypertension and crackles are manifestations of fluid overload, which is a complication of TPN related to the fluid infusion rate. 27. A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. Rationale: Allowing the child to ambulate in his room alone does not increase the child’s safety risk appreciably and has other benefits for the client. B. Limit contact with other pediatric clients. Rationale: Contact with other clients on the pediatric unit does not increase the child’s safety risk appreciably and has other benefits for the client. C. Initiate seizure precautions for the child. Rationale: A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to implement seizure precautions for this client. D. Have the child use a wheelchair for all out-of-bed activities. Rationale: Having the child use a wheelchair is unnecessary and does not ensure the child’s safety. 28. A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop? A. Place sandbags to maintain right plantar flexion. Rationale: Sandbags can be used to support the foot in a dorsiflexion position. Plantar flexion positions the foot with toes down, contributing to foot-drop. B. Position soft pillows against the bottom of the feet. Rationale: Placing firm pillows against the bottom of the feet will help to maintain a position of dorsiflexion. Soft pillows will not provide a firm enough surface to prevent foot-drop. C. Support the right foot in dorsiflexion with a footboard. Rationale: The foot should be positioned in a dorsiflexion position using a firm surface, such as a footboard. When foot-drop occurs, the foot is permanently fixed in plantar flexion with toes pointing downward. D. Splint the right lower extremity to maintain proper alignment. Rationale: The leg should not be splinted. Support the foot in dorsiflexion with ankle-foot orthotic or high-top tennis shoes. 29. A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following should be addressed by an occupational therapist? A. Using assistive devices Rationale: As a member of the interdisciplinary team, the physical therapist would help the client achieve gross mobility skills, such as facilitating ambulation and teaching the client to use a walker or crutches. The physical therapist also may assist with ADLs, such as transferring from bed to chair, ambulating, and toileting. B. Completing self-care Rationale: As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping. C. Thickening clear liquids Rationale: As a member of the interdisciplinary team, the speech-language pathologist would provide screening for clients who have dysphagia. The speech-language pathologist evaluates and retrains clients who have speech, language, or swallowing problems. If the client has a problem with swallowing, appropriate food and feeding techniques would be recommended. Thickening clear liquids would reduce the risk of aspiration in a client who has dysphagia by increasing the liquid’s viscosity and making it easier to swallow. D. Transferring from chair to bed Rationale: As a member of the interdisciplinary team, the physical therapist would help the client achieve gross mobility skills, such as facilitating ambulation and teaching the client to use a walker or crutches. The physical therapist also assists with ADLs, such as moving in and out of the bed, ambulating, and toileting. 30. A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate intervention? A. Tilt the head and lift the chin. Rationale: Tilting the head and lifting the chin is an appropriate intervention to open the airway if the client loses consciousness. B. Begin the Heimlich maneuver. Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. C. Turn the client to the side. Rationale: Turning the client to the side is an appropriate intervention if the client is unconscious and breathing. D. Perform a blind finger sweep. Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction. 31. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse recognize as a complication of this therapy? A. Polyuria Rationale: TPN is prescribed when extensive nutritional support for prolonged periods of time is required. It is delivered through a central venous access device, usually via the internal jugular or subclavian vein. TPN contains a high concentration of dextrose, which can result in hyperglycemia. Clinical manifestations of hyperglycemia include polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be implemented in clients receiving TPN. Administering regular insulin according to a sliding scale will help control glucose levels. B. Aspiration Rationale: Aspiration is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. One of the complications of TEN is pulmonary aspiration. This can occur if the tube is not placed correctly (e.g., in the lungs instead of the stomach) or if feedings are administered too rapidly or in too large a volume. Ensuring the tube is placed correctly and maintaining the client in a Fowler’s position will minimize this risk. Because TPN is not administered via the GI tract, aspiration is not a complication. C. Diarrhea Rationale: Diarrhea is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. Diarrhea can occur if the feedings are delivered too rapidly. Feedings should be started slowly and advanced as tolerated. Because TPN is not administered via the GI tract, diarrhea is not a complication. D. Stomatitis Rationale: Although mouth care is important for clients who are receiving supplemental nutrition, stomatitis is not expected. Stomatitis is an inflammation of the lining of the mouth that may include the inside of the cheeks, gums, and tongue. It can be caused by chemotherapy. It is not caused by TPN. 32. A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client’s IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20 mL/hr. Rationale: The nurse who slows the IV rate to 20mL/hr may compromise volume resuscitation and cause hypotension. B. Continue the rate at 125 mL/hr. Rationale: The nurse who continues the IV rate at 125 mL/hr may worsen the client’s condition by rapidly expanding the client’s plasma volume. C. Slow the rate to 50 mL/hr. Rationale: The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure. D. Increase the rate to 250 mL/hr. Rationale: The nurse who continues the IV rate at 250 mL/hr may worsen the client’s condition by rapidly expanding the client’s plasma volume and causing increased intracranial pressure. 33. A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective? A. Hct 43% Rationale: An Hct of 43% is within the expected reference range but this does not indicate the TPN therapy is effective. Clients with cancer are likely to have a low Hct due to anemia. B. WBC 8,000/uL Rationale: A WBC count of 8,000/uL is within the expected reference range but this does not indicate the TPN therapy is effective. Clients receiving TPN are at risk for developing infection. C. Albumin 4.2 g/dL Rationale: Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein. D. Calcium 9.4 mg/dL Rationale: A calcium level of 9.4 mg/dL is within the expected reference range but this does not indicate the TPN therapy is effective. Clients receiving TPN are at high risk for developing hypercalcemia. 34. A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips. Rationale: Cyanotic fingertips is not an indicator that a client is experiencing increased intracranial pressure. B. Nuchal rigidity. Rationale: Nuchal rigidity is not an indicator that a client is experiencing increased intracranial pressure. C. Fever. Rationale: Fever is not an indicator that a client is experiencing increased intracranial pressure. D. Diplopia. Rationale: Clients who have meningitis can be at risk for developing increased intracranial pressure (ICP). The classic triad of manifestations for increased ICP consists of headache, nausea/vomiting, and diplopia, or double vision. The client who has meningitis and reports diplopia must be carefully monitored for other manifestations of increased ICP. 35. A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Rice is low in fiber and provides carbohydrates. B. Poached eggs Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Poached eggs are low in fiber and a good source of protein. C. Fresh apples Rationale: Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead. D. White bread Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. White bread is low in fiber and provides carbohydrates. 36. A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When assessing the client receiving this therapy, which of the following observations by the nurse is of least importance? A. IV site Rationale: It is essential that the nurse assess the IV site, regardless of the fluid delivery system. B. Height of IV pole Rationale: Since the TPN is infusing via an IV infusion pump, the height of the IV pole is irrelevant. Gravity is not an issue with an infusion pump, which controls the flow of the solution via mechanical means. C. Date on tubing Rationale: It is essential that the nurse assess the date on the IV tubing. The tubing for a TPN infusion must be changed daily. In addition, the tubing itself should be assessed thoroughly. Tubing can become kinked, leading to an obstructed flow of IV fluid. If the connections are not secure, breaks in the system are potential portals of entry for infection. D. Contents of solution bag Rationale: It is essential that the nurse verify that the solution infusing is the solution ordered. 37. A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk? A. Inability to regulate body temperature Rationale: The nurse should be aware that the hypothalamus controls body temperature, fluid balance, particular emotions (such as pleasure and fear), sleep, and appetite. B. Bradycardia Rationale: The nurse should be aware that bradycardia results from a problem in the medulla oblongata rather than the hypothalamus. C. Visual disturbances Rationale: The nurse should be aware that the visual area is controlled by the occipital lobe rather than the hypothalamus. D. Inability to perceive sound Rationale: The nurse should be aware that the auditory center is located in the temporal lobe rather than the hypothalamus. 38. A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? A. Pushes the painful stimulus away. Rationale: The client who pushes the painful stimulus away is a normal response that is purposeful and appropriate. B. Extends the body part toward the stimuli. Rationale: The client who extends the body part toward the stimuli indicates increased intracranial pressure and is not a normal response. C. Shows no reaction to the painful stimuli. Rationale: The client who shows no reaction to the painful stimuli is not a normal response and may indicate flaccidity and may be neurological impaired. D. Flexes the upper and extends the lower extremities. Rationale: The client who flexes the upper and extends the lower extremities is not a normal response and indicates decorticate or decerebrate. 39. An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A. A reddened area over the sacrum Rationale: A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage. B. Stiffness in the lower extremities Rationale: Depending on the location and extent of the CVA, varying degrees of leg stiffness are typical findings. C. Difficulty moving the upper extremities Rationale: Depending on the location and extent of the CVA, varying degrees of mobility impairment are typical findings. D. Difficulty hearing some types of sounds Rationale: Presbycusis, or age-related sensorineural hearing loss, is typical among older adults and is not a complication of immobility. 40. A nurse is caring for an older adult client who is hospitalized for a bowel obstruction and has a nasogastric (NG) tube to wall suction. Which of the following nursing interventions should be included in the postoperative plan of care? (Select all that apply.) A. Offer small amounts of clear liquids after the client's gag reflex returns. B. Maintain the client on complete bed rest for 48 hr. C. Irrigate the nasogastric tube with saline as needed. D. Place sequential compression devices on the bilateral lower extremities. E. Reposition the client from side to side every 2 hr. F. Encourage the use of an incentive spirometer every hour while the client is awake. Rationale: Offer small amounts of clear liquids after the client's gag reflex returns is incorrect. Offering of clear liquids is contraindicated in a client who has a nasogastric tube. In addition, the client's diet will not be resumed until bowel sounds, rather than the gag reflex, have returned. Irrigate the nasogastric tube with saline as needed is correct. A nasogastric tube will be in place following surgery for a bowel obstruction to provide gastric decompression. The tube should be irrigated as needed to maintain patency. Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow in a client who has impaired mobility and should be in place on the lower extremities whenever the client is in bed. Reposition the client from side to side every 2 hr is correct. All clients who are postoperative should be repositioned, either alone or with assistance, every 2 hr. Encourage the use of an incentive spirometer every hour while the client is awake is correct. Use of the incentive spirometer helps to prevent the development of atelectasis. All clients who are postoperative should be encouraged to use the device 10 times each hour while awake. 41. A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states A. "Could you get me a bowl? I feel nauseated." Rationale: Nausea and vomiting may occur with increased ICP. The classic three symptoms of increased ICP in a conscious client are nausea, headache, and diplopia (double vision). A client report of nausea should be investigated immediately. B. "I'm so bored in here. I want to go home." Rationale: This is a statement that may be heard from many clients recovering from surgery, especially if the client has been hospitalized for nearly a week. C. "Can you assist me to the bathroom? I need to urinate." Rationale: This client will require assistance in getting to the bathroom. D. "I think I'm constipated. I haven't had a stool since before surgery." Rationale: This issue should be addressed, but this is not an early sign of increased ICP. 42. A nurse is planning care for a client who has a decreased level of consciousness from bacterial meningitis. The client is receiving continuous nourishment via gastrostomy tube (G-tube) feedings due to an inability to swallow. Which of the following is the priority action by the nurse? A. Turn and position the client every 2 hr. Rationale: This is not the priority action by the nurse. B. Elevate the head of the client's bed 30° to 45&#176. Rationale: Elevating the head of the client's bed will decrease the risk of aspiration. C. Change the client’s G-tube dressing. Rationale: This is not the priority action by the nurse. D. Place sequential compression devices (SCDs) on the client while in bed. Rationale: This is not a priority action by the nurse. 43. A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following? A. Brudzinski’s sign Rationale: Brudzinski’s sign is an involuntary, spontaneous flexion of both hips and knees when the neck is flexed. It indicates meningeal irritation. Only some clients with meningitis display this sign, however. B. Chvostek’s sign Rationale: Chvostek’s sign is a response of facial twitching when the nurse taps the client’s face over the facial nerve. It indicates hypocalcemia, not meningeal irritation. C. Goodell’s sign Rationale: Goodell’s sign is a softening of the cervix of the uterus. It is a probable finding during pregnancy. D. Kernig’s sign Rationale: Kernig’s sign is an inability to extend the leg completely when sitting or lying with the thigh flexed on the abdomen. Only some clients with meningitis display this sign, however. 44. A nurse is assessing a client who has obstruction of the common bile duct due to cholelithiasis. Which of the following is an expected finding? A. Fatty stools Rationale: An expected client finding is fatty stools due to biliary obstruction causing a lack of bile for the absorption of fats in the intestines B. Straw-colored urine Rationale: Chronic cholecystitis may result in dark urine not straw-colored urine due to biliary obstruction. C. Tenderness in the left upper abdomen Rationale: Chronic cholecystitis may result in tenderness in the right upper abdomen due to biliary obstruction and inflamed gallbladder. D. Ecchymosis of the extremities Rationale: Chronic cholecystitis may result in jaundice due to biliary obstruction. 45. A nurse is caring for a client who is one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as personal protection equipment? A. Talking to the client at the bedside. Rationale: Standard precautions does not require the nurse to wear personal protective equipment while being in the room of a client who is HIV positive. B. Administering an IV piggyback medication. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. There is no risk to the nurse to be in contact with body fluids while administering an IV piggyback medication. C. Completing a dressing change. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. While performing a dressing change on a client who is HIV positive, the nurse should wear appropriate personal protective equipment, which includes a gown. D. Administering an IM injection. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. The nurse should wear gloves when administering an IM injection to this client. 46. A nurse on the pediatric unit is notified that a child is being admitting following an appendectomy and is to be placed in a room with another client. The nurse should plan to place the child with which of the following clients? A. A child with sickle cell crisis. Rationale: he greatest risks to the child with sickle cell crisis are from inadequate rest and pain management. The nurse should not place another client in the room of a child with sickle cell crisis due to the frequent assessments and interventions required when caring for the client with an appendectomy. B. A child with tonsillitis. Rationale: The greatest risk to the client following surgery is from infection. Placing the postoperative client in the room of a child with an infection is not appropriate. C. A child with head injury. Rationale: The greatest risks to the client following head injury are from stimulation and inadequate pain management. The nurse should not place another client in the room of a child with head injury due to the frequent interruptions that will occur when providing care during the postoperative period. D. A child with type 1 diabetes. Rationale: he greatest risk to the client following surgery is from infection. Placing this client in the room of a child with diabetes is appropriate since this child requires monitoring and teaching. 47. A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution? A. Reduce edema of the brain. Rationale: An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream. B. Provide fluid hydration. Rationale: An osmotic diuretic is used to rapidly reduce intracranial edema and is not used to provide fluid hydration. C. Increase cell size in the brain. Rationale: An osmotic diuretic is used to rapidly reduce brain size, not increase the cell size of the brain. D. Expand extracellular fluid volume. Rationale: An osmotic diuretic is used to rapidly reduce extracellular fluid volume to decrease brain edema. 48. A nurse is caring for a 5-month-old undergoing a lumbar puncture to rule out meningitis. The nurse who is planning to assist with the procedure should A. utilize a papoose board to restrain limbs. Rationale: A papoose board would be used for a procedure done on the anterior side of the body, but it would not be appropriate for visualizing or accessing the lower spine. B. position the infant seated on the side of table. Rationale: This might be an option for an adolescent or adult, but not an infant. C. have several other nurses help hold the infant. Rationale: One nurse is usually able to assist with this procedure. D. hold the infant's chin to his chest and knees to his abdomen. Rationale: The client is positioned on the side in a fetal position (knees curled to abdomen and chin tucked to chest). 49. A nurse is planning care for a 6-year-old client who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in semi-Fowler's position. Rationale: Semi-Fowler's position, with the head of bed elevated 30 to 45 degrees, will help to reduce edema in the brain. B. Admit the client to a private room. Rationale: Isolation for the first 24 hours of a client who has bacterial meningitis is indicated due to the highly contagious nature of some types of bacterial meningitis. Decreasing the environmental stimuli is an important action in the care of a client with meningitis. C. Measure head circumference every shift. Rationale: The head circumference of a 6-year-old can't increase since the fontanels and sutures have all been closed since the child was 18 months old. Therefore, it would be unnecessary to measure the client's head circumference. D. Implement seizure precautions. Rationale: This client has an increased risk for seizure activity. First, the meningitis itself and corresponding brain edema and meningeal irritation can result in seizure activity. Second, the client who has meningitis typically has a very high fever, increasing the risk of febrile seizure. Placing the client on seizure precautions helps to prevent client injury should the client have a seizure. 50. After receiving TPN at 84 ml/hr continuously for five days, a client, in a state of confusion, pulled out their central line. Prior to notifying the physician, the nurse should start a peripheral IV and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. Rationale: This is not the appropriate intervention for the nurse to take. B. Change the tubing and filter on the TPN. Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to take. C. Hang an infusion 10% dextrose. Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to experience hypoglycemia. Administering an infusion of 10% dextrose will adjust the client’s blood glucose levels. D. Notify the pharmacy. Rationale: This is not the appropriate intervention for the nurse to take. 51. A nurse is caring for a school-age child who sustained a closed head injury. Which of the following findings is an early indicator of increased intracranial pressure? A. Pupils 4 mm and reactive. Rationale: The pupils are reactive, which is normal. Several factors can cause a change in pupil size, including medications. Ocular signs such as fixed, dilated, and unequal pupils indicate increased ICP or brainstem involvement. A child who is comatose and has asymmetric pupils or one pupil that is dilated and nonreactive constitutes a medical emergency. B. Irritability Rationale: A decrease or change in level of consciousness is typically the first sign of deterioration in neurological status. Changes in consciousness or orientation are due to injury to the cerebral cortex and may also involve damage to the reticular activating system within the brainstem. Early indicators of a change in LOC include behavior changes (restlessness, irritability) and disorientation, which are often subtle in nature. Head injuries can be classified as open (skull integrity is compromised-penetrating trauma) or closed (skull integrity is maintained-blunt trauma). Head injuries are also classified as mild, moderate, or severe, depending upon Glasgow Coma Scale (GCS) ratings and length of loss of consciousness. GCS scores of 8 or less are associated with severe head injury and coma. GCS scores between 9 and 12 indicate moderate head injury. GCS scores of 13 to 15 and a loss of consciousness for up to 15 min reflects minor head trauma. C. Bradycardia and hypertension Rationale: Cushing’s triad, a classic but late sign of increased ICP, is manifested by severe hypertension with a widened pulse pressure and bradycardia. As ICP continues to increase, the pulse becomes thready, irregular, and rapid. Cerebral blood flow increases in response to hypertension. D. Glasgow Coma Scale of 14 Rationale: The Glasgow Coma Scale is a tool used to measure a client’s neurological status. The numerical scale ranges from 3 to 15. A higher score indicates a higher level of consciousness. A score of 7 or less indicates a coma. A score of 3 is associated with a poor prognosis. A score of 14 is not a priority concern. 52. A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client? A. Cough and deep breathe. Rationale: A closed-head injury is caused by blunt trauma to the head. As a result, edema can occur within the brain and lead to increased intracranial pressure (ICP). An initial sign of increased ICP is often a decrease in the level of consciousness. Other manifestations include nausea and vomiting, changes in sensorimotor status, and pupillary changes. In severe cases, Cushing’s triad (hypertension, bradycardia, and a widening pulse pressure), abnormal posturing, and seizures can occur. Deep breathing, coughing, and blowing the nose should be avoided because these actions may increase ICP even more. B. Elevate the head of the bed. Rationale: A closed-head injury can result in edema within the skull and increased intracranial pressure (ICP). Manifestations of increased ICP include changes in level of consciousness, nausea and vomiting, changes in sensorimotor status, and pupillary changes. An important intervention includes positioning the client in a neutral position with the head of the bed elevated. This allows the cerebral spinal fluid to flow freely through the brain and spinal cord and minimize pressure within the central nervous system. C. Avoid neck and hip flexion. Rationale: A closed-head injury can result in edema within the skull and increased intracranial pressure (ICP). An initial sign of increased ICP is often a decrease in the level of consciousness. Treatment of increased ICP focuses on decreasing intracranial pressure. The nurse should avoid flexion of the client’s neck and hips because these positions could potentially increase ICP by preventing the free flow of cerebral spinal fluid through the brain and spinal cord. D. Log roll when repositioning. Rationale: A closed-head injury can result in edema within the skull and increased intracranial pressure (ICP). Treatment of increased ICP focuses on decreasing intracranial pressure. An important intervention includes positioning the client in a neutral position. The client should also be log rolled when repositioned. This allows the cerebral spinal fluid to flow freely through the brain and spinal cord, and decreases the risk of a further increase in the ICP. 53. A nurse is reviewing the client’s laboratory values who is receiving total parenteral nutrition (TPN) has the following lab values: glucose = 72 mg/dL, chloride = 98 mEq/L, sodium = 138 mEq/L, and potassium = 3.0 mEq/L. Which of the following may the nurse expect to implement? A. Discontinue the TPN infusion. Rationale: The appropriate nursing action is not to discontinue the client’s TPN infusion, but to consult with the provider for interventions to address the abnormal lab values. B. Plan to infuse a potassium replacement. Rationale: The appropriate nursing action is to plan for a potassium infusion due to the client’s hypokalemia. C. Administer 50% dextrose immediately. Rationale: The appropriate nursing action is not to administer 50% dextrose, because the blood glucose value is within normal range. D. Monitor weekly weights. Rationale: The appropriate nursing action is to monitor the client’s daily when a client receives TPN, due to the increased risk for electrolyte imbalances and a need for intervention. 54. A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse’s highest priority assessment? A. Intracranial pressure Rationale: Increases in intracranial pressure can result from cerebral edema or bleeding, and this is essential to monitor after intracranial surgery. However, there is a higher assessment priority. B. Serum electrolytes Rationale: Sodium retention is a risk following intracranial surgery. However, there is a higher assessment priority. C. Temperature Rationale: Hyperthermia can result from infection and also from damage to the hypothalamus following intracranial surgery. However, there is a higher assessment priority. D. Respiratory status Rationale: The assessment priority when using the airway, breathing, circulation (ABC) approach to client care is to monitor the client’s respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia. This is the nurse’s highest assessment priority. 55. A nurse is admitting a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following actions should the nurse include in the client’s plan of care? A. Prepare to administer oxygen. Rationale: Unless the client has any indications of respiratory distress, there is no need for supplemental oxygen administration. B. Determine the amount and type of vaginal bleeding. Rationale: Bleeding may continue until the client has expelled all of the products of conception. It is important for the nurse to note the amount and type of bleeding and to monitor the client for indications of excessive blood loss. C. Instruct the client in appropriate birth control methods. Rationale: Unless the client requests it, this is not an appropriate time to discuss contraceptive options. D. Keep the client on bed rest. Rationale: Although providers sometimes prescribe this, there is no evidence to indicate that it can prevent miscarriage, and in this case, the client’s bleeding suggests that miscarriage is inevitable. 56. An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing. Which of the following should the nurse expect to observe upon assessment of this client? A. Extension of the extremities Rationale: Extension of the extremities is an indicator of decerebrate rather than decorticate posturing. B. Pronation of the hands Rationale: Pronation of the hands is an indicator of decerebrate rather than decorticate posturing. C. Plantar flexion of the legs Rationale: Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts. D. External rotation of the lower extremities Rationale: Internal rather than external rotation of the lower extremities is an indicator of decorticate posturing. 57. A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. Which of the following disorders does the infant have? A. Encopresis Rationale: Encopresis is constipation with fecal soiling. B. Enterocolitis Rationale: Enterocolitis is diarrhea involving the colon and intestines. C. Pyloric stenosis Rationale: Pyloric stenosis is a thickening of the pyloric channel resulting in an outlet obstruction. D. Hirschsprung disease Rationale: Hirschsprung disease is an inadequate motility of part of the intestine resulting in a mechanical obstruction. 58. A client’s IV bag of total parenteral nutrition (TPN) is empty, and the new bag has not arrived from the pharmacy. Which of the following is the most appropriate intervention for the nurse to make? A. Hang a bag of dextrose 10% in water (D10W) until the new bag of TPN is delivered. Rationale: If TPN runs out or is not available to hang, then the protocol requires that D10W is infused. D10W is a hypertonic solution that will maintain glucose level and prevent rebound hypoglycemia. B. Discontinue the TPN, and flush the central line with heparin. Rationale: When stopping IV infusions, the central line should be flushed with heparin solution, but the TN should not be discontinued. C. Convert the central line to a saline lock using sterile technique. Rationale: A weaning period is necessary when discontinuing TPN therapy. The central line should remain accessible for patency, not saline locked. D. Call the provider for new TPN orders. Rationale: The client has a current prescription for specific substances required in the TPN solution. The client’s weight, intake and output, and blood glucose are continuously monitored to determine therapeutic response to the TPN therapy. Asking the provider for a new order of TPN solution will delay therapy and could jeopardize the patency of the central line access. 59. A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate? A. Teach controlled coughing and deep breathing. Rationale: The nurse should instruct the client to avoid coughing which increases intracranial pressure. B. Provide a brightly lit environment. Rationale: The nurse should provide the client with a nonstimulating environment to limit the risk of seizure activity. C. Elevate the head of the bed 30 degrees. Rationale: The nurse should elevate the head of the bed 15 to 30 degrees to promote reduction of intracranial pressure. D. Encourage a minimum intake of 2000 mL/day of clear fluids. Rationale: The nurse should place the client on a fluid restriction to avoid increasing intracranial pressure. 60. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is a priority action for the nurse to take? A. Prepare the child for a lumbar puncture. Rationale: A lumbar puncture is a definitive diagnostic test for bacterial meningitis. However, it is not the priority action for the nurse to take. B. Administer an intervenous antibiotic. Rationale: Administering antibiotics prior to diagnostic testing may alter results. However, it is not the priority action for the nurse to take. C. Obtain blood cultures. Rationale: Blood cultures are obtained to identify the causative organism of the infection. However, it is not the priority action for the nurse to take. D. Place the child in isolation. Rationale: Bacterial meningitis is highly contagious. Therefore, the nurse should protect others from infection by placing the child in isolation. 61. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). To determine if the client is experiencing pain, the nurse should use A. pulse and blood pressure findings. Rationale: Vital signs are objective methods of evaluating pain and may not be reliable. B. behavioral indicators and affect. Rationale: Behavioral indicators are objective methods of evaluating pain and may not be reliable. C. facial expressions and grimaces. Rationale: Facial expressions are objective methods of evaluating pain and may not be reliable. D. a self-report pain rating scale. Rationale: Expressive aphasia does not necessarily mean that a client is unable to reliably report pain. When assessing a client for pain, it is always better to use a subjective method, such as a client report, than an objective method, such as something that is observable by the nurse. 62. A nurse is caring for a client who has a long history of peptic ulcers and is admitted for treatment of pyloric obstruction. The nurse is preparing to insert a nasogastric tube. Which of the following options is the rationale for the use of the nasogastric tube? A. Determine the pH of the gastric secretions Rationale: This is not the purpose of a nasogastric tube. B. Supply nutrients via tube feedings Rationale: Because of the obstruction, tube feedings are contraindicated. C. Decompress the stomach Rationale: Due to a pyloric obstruction, removal of gastric secretions and gas from the stomach is needed. This is the purpose of the nasogastric tube. D. Administer medications Rationale: This is not the purpose of a nasogastric tube. 63. A nurse is reviewing medications for a client who has a diagnosis of a small bowel obstruction. The nurse should withhold senna (Senoket) prescribed orally based on understanding of which of the following? A. Laxatives are contraindicated in clients who have a small bowel obstruction. Rationale: Laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort. Bulk-forming laxatives such as psyllium (Metamucil) also are contraindicated in small bowel obstructions because they soften the fecal mass and increase the bulk of the stool. B. Only bulk-forming laxatives such as psyllium (Metamucil) should be prescribed. Rationale: All laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort. Bulk-forming laxatives such as psyllium (Metamucil) are contraindicated in small bowel obstructions because they soften the fecal mass and increase the bulk of the stool. C. Medication should be administered via NG tube rather than the oral route. Rationale: Most clients with an obstruction will have an NG tube unless the obstruction is mild. However, laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation because the bowel does not allow for any passage of stool with a complete small bowel obstruction. Laxatives will only increase abdominal cramping and discomfort. D. Opioid analgesics, rather than laxatives, should be prescribed to alleviate discomfort. Rationale: Opioid analgesics decrease intestinal motility and may cause vomiting, paralytic ileus, or exacerbation of obstruction. Opioid analgesics should be administered cautiously. 64. A nurse is caring for a client who has hemianopsia following a cerebrovascular accident (CVA). The nurse should document an improvement in this condition when the nurse observes that the client A. walks independently with a cane. Rationale: This indicates an improvement in hemiplegia, which is paralysis of one side. B. eats items from both sides of her lunch tray. Rationale: Hemianopsia, blindness in one half of the visual field, is a functional defect that can affect the right or left side. A client who had a CVA and has weakness of, for example, the right arm and leg may also have right-sided hemianopsia. Some clients lose sight primarily in the upper or lower part of the visual field, whereas others lose sight in one-half of the visual field on the affected side. An improvement in hemianopsia allows the client to see from a more complete visual field. C. has infrequent episodes of crying. Rationale: This indicates an improvement in labile or uncontrollable emotions, which are common following a CVA. D. maintains communication with others. Rationale: This indicates an improvement in aphasia, which is difficulty with receptive or expressive communication. 65. A nurse is caring for a client who is diagnosed with a cerebrovascular accident (CVA, stroke). Which of the following actions should be implemented to prevent deep-vein thrombosis (DVT)? A. Massage lower extremities daily. Rationale: DVT is common in clients who have poor circulation and who sit for long periods of time. Prevention of DVT includes client education, leg exercises, early ambulation, adequate hydration, graduated compression stockings, and intermittent pneumatic compression, such as sequential compression devices and venous plexus foot pumps. The nurse should refrain from massaging lower extremities in the event that the client has an existing DVT. Massage can promote the dislodging of the thrombus. B. Check for positive Homans’ sign. Rationale: People who have DVT may have symptoms or be asymptomatic. The classic signs and symptoms of DVT are calf or groin tenderness, and pain and sudden onset of unilateral swelling of the leg. Pain in the calf upon dorsiflexion of the foot (positive Homans’ sign) appears in only a small percentage of clients who have DVT, and false positive findings are common. Therefore, checking for Homans’ sign is not advised. C. Monitor the client’s level of consciousness. Rationale: Following a stroke, the nurse should continually monitor for changes in the client’s level of consciousness. The nurse should elevate the head of the client’s bed approximately 30° to reduce intracranial pressure and to promote venous drainage. D. Place sequential compression devices bilaterally. Rationale: DVT is the most common type of thrombophlebitis. DVT usually is treated using a combination of rest, anticoagulant therapy, and sequential compression devices (SCDs). The use of SCDs helps prevent blood stasis by promoting circulation. The SCDs should be measured from the middle of the foot to just below the knee or thigh and are worn while in bed. 66. A nurse is developing an educational poster regarding risk factors for cerebrovascular accidents (CVA) for a group of clients. In a listing of nonmodifiable risk factors, the nurse should include A. smoking. Rationale: Smoking is a factor that the client has an ability to change via cessation, so it is considered a modifiable risk factor. B. obesity. Rationale: Obesity is a factor that the client has some ability to change via diet, so it is considered a modifiable risk factor. C. hypertension. Rationale: Hypertension is a factor that the client has some ability to change via medication and diet, so it is considered a modifiable risk factor. D. race. Rationale: Nonmodifiable risk factors are things that the client cannot change. Race is the only factor listed in the choices that the client is unable to control. The other choices are all modifiable risk factors, which are lifestyle choices that the client may have some control over. 67. A client is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning? (Select all that apply.) A. Remove pillows prior to repositioning. B. Elevate the bed to waist height. C. Position the client towards the edge of bed with a foam wedge. D. Stand with feet wide apart. E. Face the direction of movement when positioning the client. Rationale: Remove pillows prior to repositioning is correct. Pillows inhibit upward motion often causing the client’s neck to be flexed or hyper extended according to the thickness of the pillow. Removing the client’s pillows, sheets, and blankets will assist with unencumbered movement and provide a more accurate assessment to place the client in an alignment.Elevate the bed to waist height is correct. Working at waist height promotes ergonomics and minimizes risk of injury to the individuals performing repositioning maneuvers and to the client being repositioned.Position the client towards the edge of bed with a foam wedge is incorrect. This action places the client too close to the edge of bed, which places the client at risk for injury. The client should be positioned in the opposite direction of the turn, thereby providing ample space to maintain safety. Although a foam wedge provides support to the client, the additional force towards the edge of the bed increases the risk of fall injury.Stand with feet wide apart is correct. A wide base of support when moving a client facilitates movement and minimizes risk of injury to individuals performing repositioning maneuvers. The body’s center of gravity is the pelvis. The closer the center of gravity is to the base of support, the more stable the movement. This is achieved by standing with the feet wide apart. The nurse should avoid twisting the spine or bending at the waist to minimize risk for injury.Face the direction of movement when positioning the client is correct. When positioning a client, the nurse should move the rear leg back to promote ergonomic stability. Facing the direction of movement will maintain alignment for both the client and the nurse. This prevents straining back muscles or bending at the waist. Sliding, rolling, and pushing in the same direction that the nurse faces require less energy and has less risk for injury. 68. A nurse is caring for a client who has acute pancreatitis. While evaluating the client's admission blood chemistry report, the nurse should expect to find an elevated serum A. ammonia. Rationale: If the liver is unable to convert ammonia into urea because of hepatocellular disease, ammonia levels rise in the blood. B. bilirubin. Rationale: A rise in serum bilirubin will occur if there is an excessive destruction of red blood cells or if the liver is unable to excrete the normal amounts of bilirubin produced due to liver disease. C. lactic acid. Rationale: Lactic acid levels increase when strenuous exercise, heart failure, severe infection, or shock reduce the flow of blood and delivery of oxygen throughout the body. Lactic acid levels can also increase when the liver is severely damaged or diseased, because the liver normally breaks down lactic acid. D. amylase. Rationale: Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The serum amylase level is the most important aid in diagnosing acute pancreatitis. 69. A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the client's cranial nerves, the nurse should check the function of cranial nerve III by A. testing visual acuity. Rationale: Visual acuity is tested to assess the function of the optic nerve, which is cranial nerve II. B. observing for facial asymmetry. Rationale: Cranial nerve VII is the facial nerve, which is a motor nerve that controls facial symmetry. C. eliciting the gag reflex. Rationale: Cranial nerves IX and X are the glossopharyngeal and vagus nerves, respectively. They are motor nerves that control the gag reflex. D. checking pupillary response to light. Rationale: Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light. 70. A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.) A. Tachypnea B. Hyperthermia C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure Rationale: Tachypnea is incorrect. Tachypnea is an increased respiratory rate great than 20/min. Tachypnea is not a part of Cushing’s Triad, one of the three late signs of ICP. Cushing’s Triad includes bradycardia, hypertension, and a wide pulse pressure.Hyperthermia is incorrect. A high temperature is not a classic sign of ICP.Bradycardia is correct. One of the three late signs of increased ICP is bradycardia. Psychologically, as the systolic blood pressure rises in the client, the heart rate naturally decreases. This is the body's way of trying to compensate and respond to abnormal stressors.Nonreactive dilated pupils is correct. Pupils that are dilated and nonreactive are associated with a marked increase in ICP. Unequal pupils, pupils unequal to light, and unilateral or bilateral dilated pupils should be treated as herniation of the brain until proven otherwise.Widened pulse pressure is correct. A widened pulse pressure is an increase in the difference between systolic and diastolic pressure over time (elevated systolic and decreased diastolic blood pressure). This is a sign of increased ICP. Cerebral blood flow increases in response to hypertension. The increased blood flow in turn increases the volume of brain tissue. 71. A client with severe pancreatitis is receiving total parenteral nutrition (TPN). The physician prescribes 1,800 mL to be infused at a continuous rate over 24 hr. At how many mL/hr should the nurse set the IV pump? A. 75 mL/hr Correct Rationale: 1,800 mL ÷ 24 hr = 75 mL/hr IV pumps can only be set to deliver hourly rates. Incorrect Rationale: 1,800 mL ÷ 24 hr = 75 mL/hr IV pumps can only be set to deliver hourly rates. 72. A nurse is caring for a client who has diverticular disease. When palpating the client’s abdomen where should the nurse anticipate abdominal pain? A. Lower left quadrant Rationale: The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon where high pressure to move fecal contents from the rectum causes pouch formation. B. Upper left quadrant Rationale: The nurse should not expect the client to have abdominal pain in the upper left quadrant area because the disease is generally located in the sigmoid colon. C. Lower right quadrant Rationale: The nurse should not expect the client to have lower right quadrant abdominal pain because the disease is generally located in the sigmoid colon. D. Upper right quadrant Rationale: The nurse should not expect the client to have upper right quadrant because the disease is generally located in the sigmoid colon. 73. A nurse is planning possible interventions in the care for a client who may need for total parenteral nutrition (TPN). Which of the following clients should benefit from TPN? A. A client who has acute gastritis Rationale: A client who has acute gastritis is able to eat and should not the need to receive TPN for nutritional supplement. B. A client who has a complete bowel obstruction Rationale: A client who has a complete bowel obstruction is in need of nutritional support and should receive TPN for nutritional supplement. C. A client who has been vomiting for the past 4 hr Rationale: A client who has vomited for the past four hours may be dehydrated but does not require TPN for nutritional supplement. D. A client who has undergone a cholecystectomy Rationale: A client who has undergone a cholecystectomy does not require TPN for nutritional supplement because the client may eat after surgery. 74. A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. Rationale: The client’s ability to follow commands earns a score of 6 for best motor response. B. The client is unable to make vocal sound. Rationale: The inability of the client to make vocal sounds earns a score of 1 for best verbal response. C. The client is unconscious. Rationale: The unconscious client earns a score of 1 for eye opening and a 1 for best verbal response. D. The client opens his eyes when spoken to. Rationale: A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain. 75. A nurse is providing education to a client who is being discharged home with total parenteral nutrition (TPN). Which of the following statements by the nurse is most appropriate? (Select all that apply.) A. “Keep the TPN refrigerated when not in use.” B. “Warm the TPN bag in the microwave before hanging.” C. “Shake the TPN bag before administering.” D. “Stop using TPN once weight gain is achieved.” E. “Maintain TPN infusion rate when behind schedule.” Rationale: “Keep the TPN refrigerated when not in use.” is correct. TPN should be stored in the refrigerator to maintain the integrity of the substances. These ingredients provide nutritional support and daily requirements to clients who cannot eat food by mouth or achieve nutrition from a diet for more than a week. TPN is required by clients who have pancreatitis, ulcerative colitis, Crohn’s disease, burn injury, cancer, AIDS, and starvation.“Warm the TPN bag in the microwave before hanging.” is incorrect. To warm the TPN to room temperature, remove the TPN bag from the refrigerator at least 2 to 4 hr before the infusion time. Never warm the TPN bag in the microwave, because this can cause hotspots in the solution.“Shake the TPN bag before administering.” is incorrect. To preserve the integrity of the TPN contents, the client should be instructed to gently rock the TPN bag back and forth, up and down. This action gently blends the solution in the bag prior to administration. The force of shaking the bag would negatively impact the molecular structure of the various substances contained in the TPN bag.“Stop using TPN once weight gain is achieved.” is incorrect. The rate of TPN infusion should not be changed without the guidance of the provider. A weight gain or loss should be reported to the client’s provider to make the necessary adjustment in TPN infusion rate. Abrupt discontinuation can impact of the client’s glucose level and cause hyperglycemia or hypoglycemia. “Maintain TPN infusion rate when behind schedule.” is correct. The rate of TPN infusion should not be changed without the guidance of the provider. TPN is a hypertonic solution and should be slowly decreased in rate with a strategic plan to discontinue therapy over time. An increase or decrease in TPN infusion rate can impact of the client’s glucose level and cause the complication of hyperglycemia or hypoglycemia. [Show More]

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