1470 ALL PRACTICE EXAM QUESTIONS AND ANSWERS FOR PN MEDICAL-SURGICALADULT MEDICAL SURGICAL 2022 100% CORRECT ANSWERED QUESTIONS WITHEXPLANATION

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1470 ALL PRACTICE EXAM QUESTIONS AND ANSWERS FOR PN MEDICAL-SURGICAL ADULT MEDICAL SURGICAL 2022 100% CORRECT ANSWERED QUESTIONS WITH EXPLANATION A nurse is caring for a client who has a percutaneo... us endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water. B. Place the client in semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents. - CORRECT ANSWER B. Place the client in semi-Fowler's position. A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen - CORRECT ANSWER A. A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. B. CORRECT: An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction. C. Identifying an obstruction in the biliary tract is performed during endoscopic retrograde cholangiopancreatography (ERCP). D. The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not an EGD. A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer." - CORRECT ANSWER A. A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus. is performed to monitor for the presence of acid in the normally alkaline esophagus. B. CORRECT: An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. C. An EGD is performed while the client receives moderate sedation. D. A colonoscopy is performed to detect colon cancer. A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? A. A full pitcher of water is sitting on the clients bedside table within the clients reach. B. The disposable feeding bag from the previous day at 1000, and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated 20 degrees. - CORRECT ANSWER A. the nurse should monitor the clients intake and output and should observe the client for manifestations of dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of water at the clients bedside does not require intervention by the nurse. B. The clients feeding bag should be changed every 24 hrs. The 200 mL remaining in the bag is sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will ensure that the bag does not run dry, causing air to enter the clients stomach. C. This observation does not require intervention because the feeding is not by gravity, but by a pump. and is set at a constant rate. The clients side-lying position will not affect the pump's rate of flow unless the client is lying on the tubing. D. CORRECT: The head of the bed should be elevated at least 30. (Semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis - CORRECT ANSWER A. A client experiencing fluid volume overload will exhibit hypertension. B. A client experiencing hyperglycemia will exhibit excessive thirst. C. A client who has an infection will have an increased temperature. D. CORRECT: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis. other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and hunger. A nurse is caring for a client who has celiac disease. which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes - CORRECT ANSWER A. CORRECT: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the clients tray. B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable food to include in the clients diet. C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an acceptable food to include in the client's diet. D. Mashed potatoes do not contain gluten and are a good source of protein and potassium. Therefore mashed potatoes are an acceptable food to include in the clients diet. A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium - CORRECT ANSWER A. CORRECT: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin. B. Serum lipase is monitored to detect pancreatic disease and does not need to be monitored prior to this procedure. C. Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to this procedure. D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be monitored prior to this procedure. A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen - CORRECT ANSWER A. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the skin. D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging. A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-gluramyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT] - CORRECT ANSWER A. CORRECT: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use. B. ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. C. The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. D. The largest concentration of the enzyme ALT is found in liver tissue. However. it is also present in kidney, heart. and skeletal muscle tissues. Because it is elevated in various toes of tissue damage. it is not helpful in identifying excessive alcohol use. A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories - CORRECT ANSWER A. Vitamin C functions as an antioxidant as well as a coenzyme. It can be associated with prevention of cancer of the stomach. esophagus and colon. However, it does not improve or prevent acute diverticulitis attacks. B. Low-fat foods do not improve or prevent acute diverticulitis attacks. C. CORRECT: The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract. D. Low-calorie foods do not improve or prevent acute diverticulitis attacks. A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees C (101.1 degrees F) D. Oxygen saturation 92% - CORRECT ANSWER A. CORRECT: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent position can help with client comfort. B. Urine output following surgery should be at least 30 mL/hr. Less than this amount can indicate hypovolemia or renal complications and should be reported to the provider immediately. C. A temperature greater than 38.4. C (101.1 F) can indicate infection and should be reported to the provider immediately. D. An oxygen saturation of less than 95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately. A nurse in the emergency dependent is caring for a client who has bleeding esophageal varies. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole - CORRECT ANSWER A. Famotidine is an H2 receptor antagonist used to treat stress ulcers. B. Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. C. CORRECT: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varies. D. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers. A nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces - CORRECT ANSWER A. Jaundice is a late manifestation of hepatitis A. B. CORRECT: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. C. Dark urine is a late manifestation of hepatitis A. D. Pale feces is a late manifestation of hepatitis A. A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase - CORRECT ANSWER A. Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. The levels of aldolase are not affected by pancreatic disorders. B. Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase. C. CORRECT: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days. D. Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage. A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids - CORRECT ANSWER A. Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. B. The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C. The client should avoid carbonated beverages because they can distend the stomach. causing pressure on the internal sutures or staples. Pressure can cause leaking into the peritoneum resulting in peritonitis. D. CORRECT: Clear liquids. such as water or broth. can be given for the first oral feedings. but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar. which could cause diarrhea due to hyperosmolarity. A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use - CORRECT ANSWER A. A high-calorie diet can contribute to heart disease and obesity but it does not cause chronic pancreatitis. B. A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C. tobacco use can contribute to heart disease and increases the risk of cancer development. but it does not cause chronic pancreatitis. D. CORRECT: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hyper secretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat. A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men - CORRECT ANSWER A. CORRECT: The hepatitis A virus can be contracted from the feces. bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact. B. Older adults are not often affected by or at risk for developing hepatitis A. C. Women who are pregnant are not often affected by or at risk for developing hepatitis A. D. Middle-aged men are not often affected by or at risk for developing hepatitis A. A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food - CORRECT ANSWER A. A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B. Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation C. CORRECT: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure. or hypotension, results. D. Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation. A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement - CORRECT ANSWER A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during endoscopy to target esophageal varies that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for a client who has localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. C. CORRECT: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high. even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varies through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure. A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by earring foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation." - CORRECT ANSWER A. The hepatitis A vaccine is recommended for those who travel, especially military personnel It is also recommended for other at-risk groups. B. CORRECT: Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth. especially in infants born to hepatitis B Surface antigen (HBSAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age. C. Hepatitis A is acquired by eating fruits. vegetables, shellfish. or other foods that are contaminated during handling. Hepatitis B is acquired by exposure to blood or body fluids from an infected person. D. Good personal hygiene habits and proper sanitation can help prevent the spread of hepatitis A. Which of the following symptoms will a nurse observe most commonly in clients with pancreatitis? A. Severe, radiating abdominal pain B. Black, tarry stools and dark urine C. Increased and painful urination D. Increased appetite and weight gain - CORRECT ANSWER A. Severe, radiating abdominal pain A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A. Maintain a high-fat diet and drink at least 3 L of fluid a day. B. Maintain a high sodium, high-calorie diet C. Maintain a high carbohydrate, low-fat diet D. Maintain a high-fat, high-carbohydrate diet - CORRECT ANSWER C. Maintain a high carbohydrate, low-fat diet A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding - CORRECT ANSWER A. Fried chicken A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K - CORRECT ANSWER D. Inability of the liver to use vitamin K Which of the following is a true statement regarding regional enteritis (Crohn's disease)? A. It has a progressive disease pattern B. It is characterized by lower left quadrant abdominal pain. C. The clusters of ulcers take on a cobble stone appearance. D. The lesions are in continuous contact with one another. - CORRECT ANSWER C. The clusters of ulcers take on a cobble stone appearance. A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A. Watery with blood and mucus B. Hard and black or tarry C. Dry and streaked with blood D. Loose with visible fatty streaks - CORRECT ANSWER A. Watery with blood and mucus What is the cause of a 'non-mechanical' bowel obstruction? A. A tumor or twisting of the bowel B. Constipation. C. General anesthesia, narcotics, and handling of the bowel during surgery. D. Adhesions - CORRECT ANSWER C. General anesthesia, narcotics, and handling of the bowel during surgery. What should the nurse advise a pt. who has diverticulosis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods - CORRECT ANSWER A. High fiber foods. What should the nurse advise a pt. who has diverticulitis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods - CORRECT ANSWER B. Low fiber foods. Which of the following is an appropriate nursing intervention for a patient who has had an EGD? A. Give food and water as soon as the test is completed. B. Enemas until clear. C. Monitor for hemorrhage r/t organ perforation. D. Administer a sedative. - CORRECT ANSWER C. Monitor for hemorrhage r/t organ perforation. Which of the following is an appropriate nursing intervention for a pt. who has GERD? A. Advise pt. to remain upright after meals. B. Withhold fluids during meal time. C. Administer the appropriate immunoglobulin. D. Give the prescribed steroids with half a glass of milk. - CORRECT ANSWER A. Advise pt. to remain upright after meals. Which of the following is a priority for a pt. who is hemorrhaging from a perforated duodenal ulcer? A. Administer the sedative prior to the PY test. B. Monitor for shock. C. Position the pt. on his back with a pillow under his right ribs and his right hand under his head. D. Guiac his stool - CORRECT ANSWER B. Monitor for shock. Which of the following is an appropriate nursing intervention for a pt. who has gastritis? A. Lavage the NG tube with iced saline. B. Give sucralfate with meals and follow it with antacids. C. Advise the pt. to avoid irritating foods such as spicy foods. D. Advise the pt. to drink milk every two hours. - CORRECT ANSWER C. Advise the pt. to avoid irritating foods such as spicy foods. Which of the following is an appropriate nursing intervention for a pt. who has an inguinal hernia? A. Turn, cough, & deep breath every hour while awake to prevent pneumonia. B. Avoid prolonged standing. C. Decrease fiber intake to control diarrhea. D. Monitor your stools for occult blood. - CORRECT ANSWER B. Avoid prolonged standing. Which of the following should the nurse advise a pt who has ulcerative colitis to call the doctor for? A. Occasional abdominal cramping B. Nine mucous bloody stools per day. C. Signs of colon perforation and peritonitis. D. Diarrhea. - CORRECT ANSWER C. Signs of colon perforation and peritonitis. Which of the following promotes rest and healing of the bowel in a pt. who has ulcerative colitis? A. High fiber diet B. Maintaining NPO status as ordered C. Low carb diet D. Avoiding licorice and caffeine - CORRECT ANSWER B. Maintaining NPO status as ordered Which of the following nursing diagnosis might be appropriate for a pt with ulcerative colitis? A. Pain R/T the passage of stones. B. Risk for injury from falling R/T dizziness and low BP immediately after meals. C. Fatigue R/T blood loss caused by frequent bloody stools. D. Risk of injury R/T auto digestion of the pancreas. - CORRECT ANSWER C. Fatigue R/T blood loss caused by frequent bloody stools. The prototype drug for proton pump inhibitors: - CORRECT ANSWER Omeprazole (prilosec) The action of H2 Receptor Antagonists : - CORRECT ANSWER They block histamine and reduce gastric acid production The use of metroclopramide: - CORRECT ANSWER GI stimulant to Treat GERD and Antiemetic Method ondansetron (Zofran) prevents nausea & Vomiting: - CORRECT ANSWER blocks 5- HT3 Serotonin receptors The serious side effects associated with ondansetron (Zofran): - CORRECT ANSWER arrhythmias, hypotension, & extrapyramidal effects The prototype drug for H2 Receptor antagonists: - CORRECT ANSWER ranitidine (Zantac) Reason omeprazole should not be crushed or chewed: - CORRECT ANSWER enteric Coated granules & Acid labile The drug that used to be the prototype for H2 receptor Antagonists: - CORRECT ANSWER cimetidine (Tagamet) Serious Side effects of ranitidine (Zantac): - CORRECT ANSWER neutropenia, Agranulocytosis, Thrombocytopenia Aplastic anemia The potential electrolyte imbalances w/use of aluminum hydroxide w/magnesium hydroxide: - CORRECT ANSWER Hypophosphatemia & hypermagnesiemia The diet restrictions that should be taught for treatment of peptic ulcers: - CORRECT ANSWER avoiding Highly acidic, Spicey foods, alcohol, & caffeine The reason omeprazole dose may need to be adjusted in Asians: - CORRECT ANSWER the duration Of action is lengthened The common adverse effects of magnesium hydroxide: - CORRECT ANSWER cramps, Diarrhea, and nausea Caused by overactive GI activity Barium swallow: - CORRECT ANSWER Fluoroscopic observation of a client swallowing a flavored barium solution and its progress down the esophagus to detect structural abnormalities of the esophagus as well as swallowing discoordination and oral aspiration. Barium enema: - CORRECT ANSWER Radiographic study used to identify polyps, tumors, inflammation, strictures, and other abnormalities of the colon after instilling barium solution rectally. Endoscopic retrograde cholangio-pancreatography: - CORRECT ANSWER Procedure in which an endoscope is used to visualize the common bile duct and the pancreatic and hepatic ducts through the ampulla of Vater in the duodenum. Esophagogastro-duodenoscopy: - CORRECT ANSWER Examination of the esophagus, stomach, and duodenum through an endoscope to inspect, treat, or obtain specimens from any of the upper GI structures. Melena: - CORRECT ANSWER Black, tarry stools. PY test: - CORRECT ANSWER Test in which a client's breath is analyzed after consuming 14 C-urea capsules to detect Helicobacter pylori, the bacteria associated with peptic ulcer disease. Percutaneous liver biopsy: - CORRECT ANSWER Procedure in which a small core of liver tissue is obtained by placing a needle directly into the liver through the lateral abdominal wall. Radionuclide imaging: - CORRECT ANSWER Technique used to detect lesions in organs using a radioactive natural or synthetic element that is injected intravenously or ingested orally. Ultrasonography: - CORRECT ANSWER Technique that uses high-frequency sound waves to show the size and location of organs and to outline structures and abnormalities. A nurse is completing an admission assessment of a client who has pancreatitis. which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder - CORRECT ANSWER D. Epigastric pain radiating to left shoulder A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of cullens sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the clients back. B. Palpate the clients Right lower quadrant C. Inspect the skin around the umbilicus D. Auscultate the area below the clients scapula - CORRECT ANSWER C. Inspect the skin around the umbilicus A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. A history of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked - CORRECT ANSWER D. Hand spasms present when blood pressure is checked "trouso's sign" Which dietary modification is utilized for a patient diagnosed with acute pancreatitis? A. High-protein diet B. Elimination of Coffee C. Low carbohydrate diet D. High-fat diet - CORRECT ANSWER B. Elimination of Coffee A nurse is providing care to a client who is 1 day post paracentesis. The nurse observes clear, pale-yellow fluid leaking from the puncture site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site B. Apply a dry, sterile dressing C. Attach an ostomy back D. Place the client in a supine position - CORRECT ANSWER B. Apply a dry, sterile dressing The nurse notes that the clients total bilirubin is 1.0 mg/dl. Which action by the nurse is correct? A. Access the clients sclerae for evidence of jaundice B. Check the clients stool for presence of occult blood C. Record the results as normal D. Test the clients urine for blood. - CORRECT ANSWER C. Record the results as normal You are working in the paracentesis clinic. Which of the following clients is most likely to have an adverse reaction to the lidocaine local anesthetic? A. Asian (Chinese) B. African american C. Caucasian D. Hispanic (Puerto rican) E. Native american (Navajo) - CORRECT ANSWER E. Native american (Navajo) A nurse is caring for a client who had a Paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation - CORRECT ANSWER D. Temperature elevation The physician orders cholestyramine (questran) for the client with cirrhosis. The nurse determines that the drug is effective when the client exhibits which of the following? A. Reduced serum ammonia levels B. Improved clotting ability C. Decreased complaints of pruritus D. Improved serum protein levels - CORRECT ANSWER C. Decreased complaints of pruritus A college student is diagnosed with Hepatitis A (HAV). Which of the following actions by the nurse best accomplishes the goal of reducing potential transmission of HAV? A. The nurse dons a mask and gown when providing direct care B. The nurse maintains the client in private room at all times C. The nurse preforms vigorous handwashing after leaving the room. D. The nurse wears gloves whenever entering the clients room - CORRECT ANSWER C. The nurse preforms vigorous handwashing after leaving the room. A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the clients recent laboratory findings and recognizes that which of the following findings will place the client at risk for complications? A. Low platelet count B. Low sodium level C. Decreased prothrombin time D. Low hemoglobin - CORRECT ANSWER A. Low platelet count ? You are assigned to a client who is recovering from abdominal surgery. She tells you that the client in the next room has chronic hepatitis and she is afraid she will catch it. Which answer would best help this client? A. "Don't worry. That kind of hepatitis can only be transmitted sexually" B. "There are many kinds of hepatitis. Do you know which one she has?" C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" D. "There is no problem, that client is not a carrier of the disease" - CORRECT ANSWER C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" ?? The nurse is providing care for a patient who just had a paracentesis to treat ascites. Which of the following findings indicate that the procedure was effective? A. Increased heart rate B. Presence of a fluid wave C. Decreased shortness of breath D. Post procedure weight unchanged from pre procedure weight - CORRECT ANSWER C. Decreased shortness of breath The nurse is providing care for a patient who has acute Hepatitis B. Which of the following findings should the nurse expect? A. Joint pain B. Obstipation C. Periumbilical discoloration D. Right upper quadrant tenderness - CORRECT ANSWER D. Right upper quadrant tenderness The nurse is providing discharge teaching for a patient who has chronic hepatitis C. Which of the following statements by the patient indicates an understanding of the teaching? A. "I will decrease my intake of calories." B. "I will need treatment for 3 months" C. "I will avoid alcohol until i am no longer contagious" D. "I will avoid medications that contain acetaminophen" - CORRECT ANSWER D. "I will avoid medications that contain acetaminophen" The nurse is providing care for a patient who has peritonitis. The patient expresses anxiety about the impending surgery. Which of the following actions should the nurse take? A. "Why are you feeling so anxious?" B. "Tell me more about your concerns." C. "You should distract yourself by reading a magazine" D. "You have nothing to worry about. Your surgeon is excellent." E. "Others who have had this procedure have had great results." - CORRECT ANSWER B. "Tell me more about your concerns." A client is diagnosed with Hepatitis A (HAV). Which of the following should the nurse include in client education? A. "This type of hepatitis can now be cured by using a new medication every day for 12 weeks." B. "You cannot transmit this type of Hepatitis to others unless you have unprotected sex." C. "It's just fine to continue working as a food handler as long as you wear gloves." D. "You and everyone in your household should preform good handwashing." - CORRECT ANSWER D. "You and everyone in your household should preform good handwashing." Which layer of the uterus is responsible for labor and delivery? - CORRECT ANSWER Myometrium The smooth muscle of the prostate gland contributes to what function? - CORRECT ANSWER Ejaculation What hormone stimulates the release of milk from the breast of a nursing mother ? - CORRECT ANSWER Oxytocin Women secrete less estrogen as they age. What is one effect of this decrease? - CORRECT ANSWER Osteoporosis What change in the reproductive system do men experience as a normal part of aging? - CORRECT ANSWER Prostatic hypertrophy A woman has had two pregnancies. The first pregnancy produced a healthy baby girl. The second pregnancy produced a set of twins, a boy and a girl. How would the nurse document this history? - CORRECT ANSWER GII, PII What does the term abortus mean in an obstetrical history? - CORRECT ANSWER Loss of a fetus before it was mature enough to live outside of the mother The nurse is assisting with teaching a woman about early detection of cancer. According to the American Cancer Society, how should a 52-year-old woman be instructed to monitor for breast cancer? - CORRECT ANSWER Monthly BSE and a mammogram and clinical examination yearly A woman is advised by her physician to have a mammogram. What instructions should the nurse provide to assist the patient to prepare for the examination? - CORRECT ANSWER Avoid applying deodorant or powder before the test. Which palpation pattern should women be taught to use when practicing breast self-examination ? - CORRECT ANSWER Any pattern that is consistent and covers all breast tissue The nurse is preparing a woman for a pelvic examination. Which action should the nurse take prior to the examination? - CORRECT ANSWER Have the patient void The nurse is helping a young woman prepare for her first pelvic examination. Which of the following actions by the nurse is best? - CORRECT ANSWER Teach the patient a relaxation exercise The nurse is assisting with a Papanicolaou (Pap) smear. Following specimen placement on the slide, what should the nurse do first with the slide? - CORRECT ANSWER Spray it with a fixative The nurse notes that insufflation was used on a patient who has had an endoscopic examination. What care should the nurse provide for the patient during the recovery period after the procedure? - CORRECT ANSWER Have the patient lie flat for several hours. A nurse is teaching a 30-year-old male patient about testicular self-examinations (TSE). Which of the following instructions would be included in the teaching? - CORRECT ANSWER "Monthly TSE is an important part of cancer screening." The nurse assists with patient education related to testicular self-examination (TSE). The nurse determines that teaching was effective when the patient makes which of the following statements? - CORRECT ANSWER "The TSE examination is easiest after a warm bath or shower." What should a nurse teach a 50-year-old man about monitoring for prostate problems? - CORRECT ANSWER Have a yearly digital rectal examination (DRE). The nurse provides care for an elderly man with noted breast enlargement. He denies discomfort. Which of the following statements, recorded in the chart, is most appropriate? - CORRECT ANSWER "Gynecomastia noted bilaterally, no complaints of tenderness." While performing a physical examination on a male patient, the nurse notes that the urethral opening is located on the underside of the penis. Which of the following terms best describes this condition? - CORRECT ANSWER Hypospadias The nurse is helping a patient who is scheduled to have a cystourethroscopy. Which of the following questions is most important for the nurse to ask? - CORRECT ANSWER "Do you have any allergies?" The nurse is caring for a patient who recently underwent cystourethroscopy. Which of the following instructions should the nurse provide before the patient is discharged? - CORRECT ANSWER "You should report any changes in your usual urination pattern." A patient learns he has an elevated prostate-specific antigen (PSA) and asks the nurse what this means. What is the best response? - CORRECT ANSWER "An elevated PSA can indicate prostatic hypertrophy or cancer. You should follow up as your physician advises." According to the American Cancer Society, how often should a breast self-examination (BSE) be performed? - CORRECT ANSWER Monthly The vulva includes which of the following structures? (Select all that apply.) - CORRECT ANSWER Mons pubis Bartholin's glands Clitoris Which glands produce secretions that become part of semen? (Select all that apply.) - CORRECT ANSWER Bulbourethral glands Prostate gland Seminal vesicles What assessment findings on breast palpation should the nurse report to the physician for follow-up? (Select all that apply.) - CORRECT ANSWER Puckering or dimpling of skin Asymmetrical movement of the breasts Areas of different consistency Different pointing position of nipples The LPN is providing instructions on testicular self-examination. Which of the following statements would be included in the teaching? (Select all that apply.) - CORRECT ANSWER "If you notice any lumps or unusual changes, you should call your doctor." "The left side of the scrotum usually hangs a little lower than the right." "The testicles should be round, smooth, and egg-shaped." An LPN is caring for a woman whose obstetrical history is noted as GIV, PIII, AI. The nurse knows which of the following is true about the patient's history? (Select all that apply.) - CORRECT ANSWER The woman gave birth three times One pregnancy failed to result in a live birth A client who is bedridden is complaining of joint pain. Which of the following interventions would be most helpful for providing comfort? a. Encourage the client to lie still and do not move the affected joints b. Apply a cold pack or an ice bag to the affected joints c. Administer anticonvulsant medications to use as an adjuvant therapy d.Apply a warm water bath for 15 minutes to painful joints - CORRECT ANSWER d. Rationale: An immobile client may be more likely to have joint pain from lack of movement. A non-pharmacological form of therapy is warmth from a warm water bath to the affected areas. Warm water improves circulation and can provide comfort to the site. The nurse should use a basin with warm water carefully and only for a few minutes at a time to avoid burning the client's skin. In some cases a heating pad can be substituted for the warm water. A client is told by the provider that he needs knee replacement surgery because of osteoarthritis. Which best describes shared decision making when making choices for this client's care? a. The client chooses a treatment plan presented by the provider based on the client's preferences b. The client is told of the severe consequences of not having surgery c. The client calls a meeting of providers who can teach him about his options d. The provider recruits other professionals to talk together the client about his care - CORRECT ANSWER a. Rationale: "The client chooses a treatment plan presented by the provider based on the client's preferences" is correct. Shared decision making is an important component of patient-centered healthcare in which the client and the provider work together to make a decision for a treatment plan. Shared decision making in this case would involve the client discussing his options for surgery with his provider and then making a decision based on the client's preferences and on clinical outcomes. A client is suffering from osteoarthritis in the knees and the nurse is providing care. The nurse is assessing the client's pain level and pain tolerance. Based on the nurse's understanding of pain, the nurse knows that a client's pain tolerance is most likely increased by which of the following? a. Sleep b. Boredom c. Introversion d. Anger - CORRECT ANSWER a. People have varying levels of pain tolerance, which is described as the amount of pain a person can endure. Some activities and conditions may positively affect a client's pain tolerance and may improve how pain is handled. Regular and restorative sleep can help a person to manage pain better than being sleep deprived. Other conditions that can raise pain tolerance include relaxation therapy, diversion, and social inclusion. A nurse is educating a client about his osteoarthritis and how best to manage his condition at home. Which of the following statements made by the client indicate that more teaching is necessary? a. I am going to quit smoking because it will help with my disease b. I can sit at my computer and perform my data entry job like I usually do c. I play football, but I am going to switch to walking instead d. I'm going to work on losing weight - CORRECT ANSWER b. Rationale: "I can sit at my computer and perform my data entry job like I usually do" is correct. Osteoarthritis is a type of joint disease in which the cartilage between the bones and joints breaks down, causing pain and deformity in the affected areas. A client who has osteoarthritis can make some lifestyle changes that will improve quality of life and help to control pain and disability. The client should be taught to quit smoking if he does smoke and to limit activities that cause significant pressure or damage to the joints, such as with certain contact sports. The client should also avoid or modify activities that involve repetitive actions, like data entry, which can cause further damage from repeated stress to the joints. The nurse received report on 4 clients and has decided that the client who needs methotrexate should be seen first. Which of the following clients needs methotrexate? a. A client with osteoarthritis b. A client with a bowel obstruction c. A client with rheumatoid arthritis d. A client with seizures - CORRECT ANSWER c. rationale: Methotrexate is an anti-rheumatic used to treat psoriasis or rheumatoid arthritis. Etanercept is a subcutaneous DMARD injection. The nurse understands that this drug does which of the following? a. Increases endogenous endorphins b. Reduces substance P in the tissues c. Blocks tumor necrosis factor receptors d. Decreases perception of pain - CORRECT ANSWER c. rationale: Etanercept binds with tumor necrosis factor (TNF) and blocks the TNF receptors on the cells, decreasing the symptoms of the disease. This reduces swelling and inflammation, therefore improving symptoms for the client with RA. A client takes medication for rheumatoid arthritis. The nurse reviews the client's list of medications and knows that which of the following medications is used to treat and manage rheumatoid arthritis? a. Immodium b. Indomethacin c. Imdur d. Inderal - CORRECT ANSWER b. rationale: "Indomethacin" is correct. This is an anti-rheumatic medication used most often for clients with rheumatoid arthritis. A 68-year-old patient suffers from rheumatoid arthritis in the joints of her arms, legs, and hands. The doctor has prescribed oral corticosteroid treatment for the patient's condition. Which information should the nurse include about how this medication works to treat arthritis? a. Corticosteroids counteract many neurotransmitters secreted by the brain b. Corticosteroids decrease prostaglandin levels that affect inflammation c. Corticosteroids stimulate opioid receptors to increase pain control d. Corticosteroids prevent the body from releasing the stress hormone cortisol - CORRECT ANSWER b. rationale: "Corticosteroids decrease prostaglandin levels that affect inflammation" is correct. Corticosteroids are drugs commonly prescribed for management of inflammatory conditions such as rheumatoid arthritis. They mimic the effects of the hormone cortisol in the body and decreas in prostaglandin levels, which are responsible for inflammation. They may be taken as oral tablets, used as topical treatments, or injected for relief of arthritis symptoms. "Corticosteroids prevent the body from releasing the stress hormone cortisol" is incorrect because cortisol IS a corticosteroid hormone. A client who has suffered from severe rheumatoid arthritis for 10 years has decided not to have surgery after injuring a leg in a fall. Which of the following describes how the nurse would advocate for this client in this case? Select all that apply. a. Notify the anesthesiologist about the client's need for pain control b. Seek to educate the client about the procedure c. Develop an alliance between the client and the provider d. Contact the client's family to suggest talking to the client e. Discuss the case with hospital administrators who can convince the client to change her mind - CORRECT ANSWER b. , c. rationale: "Develop an alliance between the client and the provider" and "Seek to educate the client about the procedure" are correct. A nurse must act as a client advocate, even if the nurse does not agree with all of the client's decisions. In this case, the nurse should continue to provide client care by acting as a liaison and continuing to educate the client about treatment options and outcomes. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise. - CORRECT ANSWER c. rationale: Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis. A nurse is caring for a 78-year-old client with severe, debilitating rheumatoid arthritis who lives at home with the spouse. The nurse assesses the client's level of safety in the home. Which aspects should be included as part of this home safety assessment? Select all that apply. a. Whether there is sufficient lighting b. Whether the home has ceiling fans c. Whether there is space available for a caregiver to help with the client d. Whether there are changes in floor levels e. Whether there are stairs in the home - CORRECT ANSWER a., c., d., e. rationale: When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible.When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. When caring for a client in the home, the nurse may notice safety hazards that could protect the client if changed. The client should be able to move about in the home and have assistive devices, such as grab bars in the bathroom, levers instead of round handles, and railings on stairs. The nurse should point out any obvious hazards so they can be changed as soon as possible. A client with potential rheumatoid arthritis is having laboratory testing and requires an ESR blood test. Which of the following best describes the ESR? a. The rate at which blood cells settle to the bottom of a tube containing blood b. The amount of by-product produced with muscle breakdown c. The presence of a gene that increases rheumatoid factor d. The level of antibodies present in response to an inflammatory antigen - CORRECT ANSWER a. ratoinale: A client with rheumatoid arthritis may have a laboratory test of an ESR (erythrocyte sedimentation rate), or 'sed rate' to determine the amount of inflammation present. Inflammation causes red blood cells to clump. When the cells clump, they become denser and sink to the bottom of the tube more quickly. The ESR is the rate at which blood cells settle to the bottom of a tube containing blood. The nurse is educating a client on managing gout. Which of the following statements by the client indicates more education is necessary? Select all that apply. a. "I can't wait to get home. My wife and I have our weekly wine and cheese night with friends" b. "When I have a flare-up, I try to increase my activity to get the blood flowing better and hopefully have it resolve faster" c. "I try to limit my intake of water. I feel like that helps my symptoms" d. I need to make sure I get a refill of my allopurinol for my gout" e. "Man, these tophi are incredibly painful" - CORRECT ANSWER a. , b., , c. rationale: "I can't wait to get home. My wife and I have our weekly wine and cheese night with friends" This statement indicates that more education is necessary. Wine and cheese are high in purines, which worsen symptoms of gout. Foods high in purines should be avoided. "When I have a flare-up, I try to increase my activity to get the blood flowing better and hopefully have it resolve faster" This statement indicates that more education is necessary. While activity and blood flow can help decrease pain and prevent flare ups, rest is always recommended during an actual flare up. "I try to limit my intake of water. I feel like that helps my symptoms" This statement indicates that more education is necessary. Adequate hydration is necessary to help flush the excess crystals in the system. Limiting water intake is never recommended for a client with gout. A client is being seen for treatment of gout. The client is in the acute stage of an attack of gouty arthritis. For which of the following signs or symptoms should the nurse assess? a. Pain and inflammation b. Uric acid crystals under the skin c. Kidney stones d. Bloody urine - CORRECT ANSWER a. rationale: "Pain and inflammation" is correct. Gout is a type of arthritis that develops when uric acid crystals accumulate and inflame the joints. Gout may be considered acute or chronic. During the acute stage of gout, the client may have severe pain and joints that are inflamed, red, and tender. If left untreated, gout can become chronic which leads to kidney stones, blood in the urine, and collections of uric acid crystals under the skin. "Kidney stones", "Uric acid crystals under the skin", and "Bloody urine" are incorrect. These are symptoms of chronic gout, NOT acute gout. A 67-year-old patient is being seen following an arm fracture. The patient was diagnosed with osteoporosis last year and has been making lifestyle changes to manage the condition. The physician now wants to start the patient on medication to control the disease. Which type of medication would most likely be prescribed to prevent the breakdown of bone tissue in the body? a. Bismuth Subsalicylate b. Cholinergics c. Biphosphonates d. Biological response modifiers - CORRECT ANSWER c. rationale: "Biphosphonates" is correct. Biphosphonates are drugs used for the treatment of osteoporosis. They work by preventing the breakdown of bone tissue in the body that leads to bone loss. Examples of biphosphonates include Fosamax and Boniva. A 55 year old woman has been prescribed ibandronate sodium (Boniva) for the prevention of osteoporosis. The nurse is giving the patient her prescription and should include which of the following information about taking this drug? a. The patient should not have a vitamin D deficiency b. The patient must not have suffered a fracture in the past c. The patient must have had osteoporosis for at least five years prior d. The patient cannot have a history of cancer - CORRECT ANSWER a. rationale: "The patient should not have a vitamin D deficiency" is correct. Ibandronate is a type of medication known as a biphosphonate, which works for the treatment of osteoporosis. Ibandronate works by changing how bone is formed and broken down in the body, slowing the progression of osteoporosis. The patient who takes this drug must be able to sit up for at least 60 minutes after administration. It is also not intended for those who have vitamin D deficiency, because this affects calcium levels in the body. Additionally, the patient with kidney disease should not take biphosphonates because of the risk of renal toxicity. A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the nurse is correct? a. Vitamin D reduces excretion of calcium in the kidneys b. Vitamin D minimizes the risk of kidney stones c. Vitamin D helps prevent constipation from increased calcium intake d. Vitamin D improves the absorption of calcium - CORRECT ANSWER d. rationale: "Vitamin D improves the absorption of calcium" is correct. Taken with calcium, vitamin D aids with calcium absorption which is essential for bone building and slowing the progression of osteoporosis. A 70-year-old client has been diagnosed with osteoporosis after undergoing a bone mineral density test. When reviewing the results of the test, the nurse explains to the client that the T score is which of the following? a. The amount of bone density compared to that of a healthy 30-year-old b. The test results of the DEXA scan, expressed in mg/mL c. The level of calcium found in a particular bone in the body d. The amount of radiation used with the test - CORRECT ANSWER a. rationale: "The amount of bone density compared to that of a healthy 30-year-old" is correct. A T-score of a bone mineral density test checks the amount of bone density the client has and compares it to the bone density of a healthy 30-year-old. The T-score is given so that the client understands if their bone density is above or below average levels. A home care nurse is working with a client who has osteoporosis. Which guideline for home safety would be most appropriate in preventing fractures in this client? a. Avoid using the shower and only use the bathtub to bathe every day b. Keep lights on in the stairwell, with switches accessible at the top and bottom c. Cover all cords with a throw rug taped to the floor d. Keep most items on lower shelves and in cupboards under the counter to avoid reaching high - CORRECT ANSWER d. rationale: Lower shelves is appropriate for placement of items, but not too low in cupboards. Items should be within easy reach. A client with osteoporosis asks the nurse how to prevent fractures from the condition. The nurse should tell the client to avoid which of the following positions? a. Standing with the shoulders back b. Bending at the knees c. Sitting slumped, with the head forward d. Keeping a close center of gravity - CORRECT ANSWER c. rationale: This is the only response that describes improper body alignment. A client with osteoporosis is at risk of fractures from even minor injuries. Having proper body alignment places less stress on the client's spine and can prevent fractures. The nurse should counsel the client to avoid sitting in a slumped position with the head forward and twisting at the waist while turning. The nurse is caring for a newly admitted client with osteomyelitis. Which of the following is a not a nursing priority when caring for this client? a. Applying heat for comfort b. Monitoring signs of worsening infection c. Assessing pain control d. Frequent neurovascular checks - CORRECT ANSWER a. rationale: Heat increases circulation and swelling which is contraindicated with osteomyelitis, so this is not a nursing priority. The nurse could use elevation to help with edema rather than heat, which would also help with comfort. The nurse is caring for a client with suspected osteomyelitis. Which of the following are key features of this condition? Select all that apply. a. Temperature of 101.5 degrees Fahrenheit b. Increased drainage from the affected area c. Skin ulceration around the affected area d. Constant bone pain that increases with movement e. Increased swelling around the affected area - CORRECT ANSWER a., d. , e. rationale: A fever is usually seen with acute osteomyelitis. Constant bone pain is typically how a client with osteomyelitis describes their pain. The client may also say the pain is localized and pulsating. Increased edema is associated with the infection and inflammatory response. As for increased drainage, it is often seen with CHRONIC osteomyelitis. When osteomyelitis is suspected, it is likely in the ACUTE phase. The home care nurse is caring for a client who was recently discharged from the hospital with a diagnosis of osteomyelitis. The nurse learns that the client stopped taking the prescribed oral antibiotics once symptoms improved. What is an appropriate response from the nurse? a. "I'm glad you are feeling better! You are correct that antibiotic therapy should be discontinued once you start to feel better" b. "I'm not sure why you were discharged on oral antibiotics in the first place. They are less effective than other forms of treatment" c. "The whole course of antibiotics should be completed. Even though you are feeling better, you should continue to take the medication" d. "Since you are diabetic it is important that you stop the antibiotics as soon as possible. I'm glad you were able to stop them" - CORRECT ANSWER c. rationale: The full course of antibiotics should always be taken to ensure that the infection is resolved, and resistant strains of bacteria do not develop. The nurse is working with a client who is hospitalized for osteomyelitis. The nurse notes that this is the client's third hospitalization for osteomyelitis in three months. Which of the following conditions in this client's health history does NOT put the client at higher risk for developing osteomyelitis? a. Type 2 diabetes b. Kidney stones c. Malnutrition d. Alcoholism - CORRECT ANSWER b. rationale: A history of kidney stones does not increase a client's risk of developing osteomyelitis. However, kidney disease would increase a person's risk for developing osteomyelitis because diseased kidneys increase the risk for infection, and one way infection can reach the bone is by traveling through the bloodstream. Remember, Type II DM, malnutrition, and ETOH increase a person's risk for developing osteomyelitis because they all decrease the body's defense against infection. The nurse is caring for a client who is admitted for acute osteomyelitis. The client's vital signs are as follows: Temperature: 102.1 degrees fahrenheit Blood pressure: 88/50 Heart rate: 107 Respiratory rate: 20 Pulse oximetry: 97% on room air Which orders does the nurse expect the provider to order for this client based on this set of vital signs? Select all that apply. a. Morphine 4 mg Q4H PRN b. 1,000 ml fluid bolus c. Two sets of blood cultures d. Tylenol 650 mg Q4H PRN e. STAT Lactic Acid level - CORRECT ANSWER b. , c., d., e. rationale: This client is showing classic signs of sepsis and needs the fluid bolus to support blood pressure. 2 sets of blood culture is a standard of care prior to initiating antibiotics to determine what kind of infection is present when there is one in the blood. Tylenol is appropriate because managing this client's fever is a priority. Since this client is showing classic signs of sepsis, the lactic acid level should be drawn to verify whether it is elevated. The nurse took over the care of a client with a left foot amputation done two days ago. Which of the following tasks does the nurse NOT have to complete during client care? a. Check vital signs routinely b. Position every two hours c. Contact spiritual care as needed d. Discuss the need to eat a balanced diet e. Debride the stump incision site - CORRECT ANSWER e. rationale: The nurse should not debride the incision site on the stump. The nurse should follow the surgeon's instructions on wound cleansing and dressing placement. An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color - CORRECT ANSWER b, c, e rationale: With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the clients heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents. A nurse is providing education to a community womens group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week. - CORRECT ANSWER c, d, e rationale: Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day. A nurse is helping a client to walk down the hall in the unit of the hospital. The client has recently had a prosthetic lower limb placed on his left lower leg. Which of the following should the nurse suggest to help the client to properly walk with this prosthesis? Select all that apply. a. Hike up the hip and swing the artificial leg forward with a step b. Keep the feet shoulder width apart c. Use a cane in the hand opposite the prosthetic limb d. Instruct the client to stand erect while ambulating e. Have the client look at their feet while walking - CORRECT ANSWER b., c. , d. , rationale: Keeping the feet shoulder width apart will promote balance and proper ergonomics. A cane may be used at first to assist with balance. A client who uses a prosthetic limb will take time and training from a physical therapist to learn to walk and move correctly with the limb. Correct technique will prevent stump damage and support muscle strength. The nurse can assist with proper technique as well, and should teach the client to stand erect and look ahead while walking and avoid hitching up the leg or dragging the leg when taking a step. A diabetic client arrives on the floor after a below the knee amputation and the stump is dressed and clean. Which of the following orders should the nurse implement first? a. Discuss nutrition with client b. Obtain vital signs c. Call physical therapy to see client d. Change the wound dressing - CORRECT ANSWER b. rationale: A client who uses a prosthetic limb will take time and training from a physical therapist to learn to walk and move correctly with the limb. Correct technique will prevent stump damage and support muscle strength. The nurse can assist with proper technique as well, and should teach the client to stand erect and look ahead while walking and avoid hitching up the leg or dragging the leg when taking a step. A client admitted with diabetic ketoacidosis (DKA) is very upset and concerned because a family member recently had to have an amputation due to diabetes complications. The client asks what can be done to prevent amputation. Which of the following is the best response by the nurse? Select all that apply. a. Take your diabetic medications as prescribed b. Wear slippers or shoes around the house c. Eat foods high in carbs and sugar. d. Check your feet daily before bed e. There is nothing you can do to prevent the complications - CORRECT ANSWER a., b., d. rationale: Diabetics should take their medications as prescribed to them to avoid complications. Diabetics should wear slippers or shoes around the house to protect their feet. Remember, diabetics have decreased circulation and sometimes neuropathy so they may not feel things.Diabetics should always check their feet before bed to make sure that they did not injure themselves in any way without realizing it. Remember, diabetics have decreased circulation and sometimes neuropathy so they may not feel things. A client had a bilateral above the knee amputation due to a motor vehicle accident and is tearful when the nurse lifts the blanket to view the stumps. Which of the following would the nurse consider doing to help the client with his psychological state? Select all that apply. a. Ask the client about the need for pain medication b. Call spiritual care c. Sit down and talk to the client d. Ask the client if there is family to call to come to support e. Provide the client with a menu for lunch - CORRECT ANSWER b., c., d. rationale: Spiritual care is a great resource to call to talk to the client. The nurse could sit down and talk to the client about the client's feelings and provide support to help psychologically. Family support is helpful for the client that is struggling psychologically after the loss of limbs. A nurse is working with a client who will be having limb amputation and will need a prosthetic limb. Which of the following aspects should be included during the pre-op phase of surgery for this client? Select all that apply. a. Ensure chronic conditions are stabilized b. Keep client mildly sedated c. Arrange for counseling with a psychotherapist d. Patient and family education e. Maintain adequate hydration - CORRECT ANSWER a., d., e. rationale: The nurse will need to assess lab values to ensure the client is healthy enough to undergo the procedure. Preparation for a limb amputation requires specific care and teaching to best prepare the client for the procedure. High levels of anxiety are associated with this procedure, so it is important for the nurse to educate the client and family thoroughly. The nurse can instruct the client about maintaining appropriate nutrition and hydration adequately for surgery. A client who has undergone a below-the-knee amputation is getting ready for a fitting for prosthesis. The nurse performs interventions to shrink the leg stump. Which activity is part of stump shrinkage? Select all that apply. a. The nurse uses an elastic roller bandage b. The bandage is wrapped around the stump and kept smooth c. The stump is shrunk to a point that it is half its original size d. The client needs pain medication before the procedure e. The nurse should inspect the stump before applying the bandage - CORRECT ANSWER a., b., e. rationale: After an amputation, the nurse may need to wrap the stump to shrink it in order to prepare it to fit into a prosthesis. The nurse wraps the stump using an elastic roller bandage after first inspecting the site for signs of redness or drainage. After wrapping the stump tightly, the nurse ensures that the bandage is smooth and free of wrinkles.The nurse will always inspect the area of the body being wrapped to check for any lesions, redness, openings, or bruises that may need addressed. A nurse arrives and is assigned four clients to care for. The nurse knows that which of the following clients are the least at risk for developing the need for an amputation? a. 67-year-old client with Type 2 Diabetes and diabetic neuropathy b. 32-year-old client with Type 1 Diabetes that is noncompliant with medications and diet c. 58-year-old client with peripheral vascular disease (PVD) d. 76-year-old client with COPD and CHF with edematous bilateral lower extremities - CORRECT ANSWER d. rationale: The 76-year-old client with COPD and CHF with edematous bilateral lower extremities is at the lowest risk for developing the need for an amputation. The nurse is caring for a client with a broken femur. The client is at higher risk for which of the following due to this specific bone fracture? Select all that apply. a. Deep vein thrombosis b. Pulmonary embolism c. Heart attack d. Pneumonia e. Stroke - CORRECT ANSWER b., c., e rationale: The femur is a long bone. Fractures to long bones increase the risk of a fat embolism, which can travel to the lungs and cause a pulmonary embolism.A fat embolism is possible following a long bone fracture. If this particle of fat becomes lodged in the vessels of the heart, it can cause the client a heart attack.Long bone fractures such as the femur, tibia, and pelvis, put the client at risk for a fat embolism. This embolism can travel to the heart, lungs, or brain and cause obstructed blood flow to these areas. A nurse is caring for a client who has suffered a fracture to the humerus after falling on their outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture is best described as which of the following? a. Comminuted fracture b. Oblique fracture c. Impacted fracture d. Greenstick fracture - CORRECT ANSWER c. rationale: "Impacted fracture" is correct. An impacted fracture is one in which the ends of the bone in a fracture are driven into each other. This type of fracture is most likely the result of a fall, such as onto an outstretched arm. It may also occur when the bone breaks from collapse of the structure, which is known as a buckle fracture. A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels. - CORRECT ANSWER a. rationale: This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the clients condition at discharge. A nurse is caring for a client who has suffered an arm fracture and has a fiberglass cast applied. Which information should the nurse give to the client to help him reduce swelling in the extremity? a. Elevate the cast and extremity b. Apply heat to the fingertips, such as with a heating pad c. Keep the fingers at rest to prevent increased circulation d. Check peripheral circulation by assessing capillary refill - CORRECT ANSWER a. rationale: The client with a cast in place may develop swelling in the affected extremity. Part of cast care is to teach the client how to prevent complications such as swelling and muscle atrophy. The nurse should encourage the client to keep the arm elevated and apply ice packs as needed. The client may check capillary refill, but this will not necessarily reduce swelling. Gentle exercise, such as range of motion activities, can also improve circulation and reduce swelling. A client is brought into the hospital after suffering a mid-shaft femur fracture in a motorcycle accident. After surgery to nail the broken femur, the client is stabilized and brought to the hospital room. The client begins to complain of severe pain in the femur, and numbness and tingling in the lower extremity of the affected leg. The nurse gives pain medication but the pain continues to increase. Which of the following actions should the nurse take? a. Utilize non-pharmacological measures, such as ice packs and guided imagery b. Ask the client to contact the nurse if the pain medication does not begin to work in thirty minutes c. Find out when the client last had a bowel movement, and offer a stool softener or laxative d. Contact the surgeon immediately and prepare the client for surgery - CORRECT ANSWER d. rationale: A femur fracture is a significant injury that often occurs as a result of severe trauma. Because of its large size, a broken femur can also lead to extensive complications, including compartment syndrome. Signs and symptoms of compartment syndrome include numbness and tingling on the affected leg, severe pain that is unrelieved by pain medication, pallor, and an inability to move the leg. If the nurse sees these signs, it is a medical emergency, and the client will need surgery as soon as possible. A pediatric nurse is caring for a 2-year-old child who suffered a femur fracture. The child has a cast on the leg and has been placed in Bryant's traction. Which of the following considerations must the nurse implement when working with a child who uses this traction? a. Perform range-of-motion of the affected hip every 4 hours b. The knee must be maintained at a 90-degree angle c. Provide the child with a liquid or mechanical soft diet d. Maintain the buttocks at a level just above the mattress of the bed - CORRECT ANSWER d. rationale: Bryant's traction is used for a fracture of the femur in some children. A child who uses Bryant's traction is typically less than 2 years old and weighs less than 30 pounds. While caring for this child, the nurse should ensure that the buttocks are at a level just above the mattress of the bed, as this form of traction pulls the legs and hips straight up off the bed. A nurse must give an intramuscular injection of pain medication to a patient who has suffered a left arm fracture. Which of the following situations would be a contraindication to administering medication in this manner? Select all that apply. a. The drug follows thrombolytic therapy b. A known reaction to the medication c. The patient is uncooperative d. A birthmark is at the site of injection e. The dose of the drug is over 2 mL - CORRECT ANSWER a. , b., d. rationale: If the patient has received thrombolytic therapy, an IM injection is contraindicated because of the increased bleeding potential.Any time the patient has a known reaction to a medication, the medication should be avoided. Other situations in which the nurse should not give an IM injection include if there is redness, inflammation, bleeding, or a birthmark over the injection site. A nurse is working with a client who has been wearing a fiberglass cast for an arm fracture for the past six weeks. Which intervention should the nurse perform after the cast has been removed? a. Assess capillary refill and skin color in the distal extremity b. Ask the client to push against a solid object c. Obtain an x-ray of the arm d. Perform the Weber-Rinne test with a tuning fork on the wrist - CORRECT ANSWER a. rationale: "Assess capillary refill and skin color in the distal extremity" is correct. When preparing to remove a client's cast, the provider may first order an x-ray to assess the fracture site. After the cast has been removed, the nurse should assess capillary refill in the area distal to the cast site and check the client's skin color to assess for good circulation. The newly exposed skin may itch, and the client should be instructed not to scratch it because this can cause damage to the skin. A nurse is caring for a client who has fallen out of a tree stand and has an obvious deformity to the right upper leg. What is the priority nursing action for this client? a. Stabilize the right leg b. Give the client oxygen c. Place the leg in traction d. Administer morphine - CORRECT ANSWER a. rationale: The leg should be stabilized to prevent further trauma, severe pain, and fat emboli. Basic stabilization is always the first step. If the client doesn't require surgery, traction would occur after this, otherwise the client will go to surgery for fixation. A 34-year-old client has suffered a femur fracture and is using skeletal traction while in bed. Which nursing diagnoses would be most applicable in this situation? Select all that apply. a. Fluid Volume Excess b. Acute Pain c. Risk for Peripheral Vascular Dysfunction d. Risk for Bowel Incontinence e. Risk for Impaired Gas Exchange - CORRECT ANSWER b., c., e. rationale: "Acute Pain", "Risk for Peripheral Vascular Dysfunction", and "Risk for Impaired Gas Exchange" are correct. Because the femur is such a large bone, a femur fracture has the potential to cause several complications for the affected client. The client may have activity intolerance and would be at risk of several issues, including impaired gas exchange due to immobility, and poor tissue perfusion due to potential swelling and circulatory compromise in the affected leg. The nurse will need to be vigilant with pain control for this client as well. A 15-year-old client suffered a radial fracture and the provider applied a plaster cast to the arm. What information would the nurse give to this client and the family about cast care during this time? Select all that apply. a. Do not allow the cast to rest on a hard surface until it is completely dry b. Look and feel for areas where the plaster may be cutting into the skin c. Keep the newly applied cast covered for the first 24 hours d. Perform capillary refill on the distal fingertips and notify the provider if it is more than 3 seconds e. Perform isometric exercises to prevent muscle atrophy - CORRECT ANSWER a., b., d., e. rationale: "Perform capillary refill on the distal fingertips and notify the provider if it is more than 3 seconds", "Look and feel for areas where the plaster may be cutting into the skin", "Perform isometric exercises to prevent muscle atrophy" and "Do not allow the cast to rest on a hard surface until it is completely dry" are correct. A plaster cast may be used to stabilize a fracture while it heals. This type of cast is applied wet, and the client must be careful during the time it takes to dry. A client with a plaster cast should learn how to assess capillary refill and know what to do if it is slow. The client should also be taught how to protect the cast while it dries, and taught exercises to help prevent muscle atrophy. A client is being seen for follow-up care after surgery for a fracture in which an external fixation device was placed. What is the most important part of the assessment? a. Monitor the pin sites for signs of infection b. Clean and thoroughly dry the skin under the traction c. Ensure that nothing touches the outside of the fixation device d. Assure that the traction weights hang freely - CORRECT ANSWER a. rationale: An external fixation device is applied to correct a fracture. The device is secured to the client by screws or pins that go through the skin into the underlying bone. If the client develops an infection it could quickly develop into sepsis. The MOST important action by the nurse is to monitor the pin sites and keep them clean to prevent infection. A client was in a motor vehicle accident in which he suffered a traumatic fracture in his lower leg. The nurse knows that the client is at risk for a fat embolism. What are signs and symptoms for the nurse to look for that indicate fat embolism syndrome (FES)? Select all that apply. a. Low body temperature b. Upper body petechiae c. Respiratory distress d. Renal dysfunction e. Tachycardia - CORRECT ANSWER b., c., d., e. rationale: "Respiratory distress", "Tachycardia", "Renal dysfunction" and "Upper body petechiae" are correct. A fat embolism occurs when a small piece of fat enters the bloodstream and lodges into a vein, potentially obstructing blood flow. A client who has had a traumatic fracture is at high risk of FES. Signs and symptoms of FES include respiratory distress, tachycardia, petechiae on the upper body, fever, renal dysfunction and jaundice. Nursing care for the client in FES includes IV fluid therapy, oxygen administration, DVT prophylaxis and supportive care. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction. - CORRECT ANSWER a. rationale: This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client. A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct? a. Inspect the clients distal finger joints. b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes. d. Perform range of motion on the clients wrists. - CORRECT ANSWER a. rationale: Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists. A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT - CORRECT ANSWER c. rationale: This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care. A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds - CORRECT ANSWER b. rationale: The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The clients blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time. A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications. - CORRECT ANSWER a. rationale: The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless. A client with a right arm cast for a fractured humerus states, "I haven't been able to straighten the fingers on my right hand since this morning." What action should the nurse take first? a. Assess neurovascular status to the hand b. ask the client to massage the fingers c. encourage the client to take the prescribed analgesic d. elevate right arm on a pillow to reduce edema - CORRECT ANSWER a. rationale: this symptom suggests neurologic injury caused by pressure on nerves and soft tissue because of swelling (compartment syndrome). Other symptoms of neurovascular compromise should be assessed and reported to the healthcare provider. Massaging the fingers will not help alleviate the problem. An analgesic will not help with mobility caused by neurologic injury and there is no evidence the client is experiencing pain. Elevating the limb could worsen symptoms at a time when circulation is already impaired from swelling, which led to the neurologic injury. A client had a left above-the-knee amputation today. For the first 24 hours post-operatively, the nurse performs which priority action to properly manage the surgical site? a. elevate the residual limb b. loosen the dressing q4 hrs c. maintain the residual limb in a dependent position d. change the dressing as often as needed - CORRECT ANSWER a. rationale: Elevating the limb during the first 24 hrs facilitates venous return, decreases swelling, and promotes comfort. The dressing is usually a compression type to mold the residual limb and to decrease the edema associated with inflammation, so loosening the dressing is an inappropriate intervention. Placing the residual limb below the heart level increases risk of edema at the surgical site. The dressing would be changed as ordered but is not usually done for the 1st 24 hrs to reduce edema, which could disrupt the surgical incision. A client with a femoral fracture is in Buck's traction. While making rounds, the nurse notices that the client's foot is touching the footboard of the bed. What is the appropriate action by the nurse? a. Wedge a pillow between the footboard and the client's foot b. Praise the client for maintaining countertraction c. Center the client on the bed d. Ask the client to pull up in bed while holding the weights - CORRECT ANSWER c. rationale: the aim in traction is to maintain a constant force to align the distal and proximal ends of a fractured bone. To be effective, the traction must have an opposing force (counter-traction). Centering the client in bed maintains the line of pull and ensures that countertraction is maintained. Placing a pillow between the foot and the footboard attempts to relieve pressure on the the foot but ignores that this position interrupts the proper pull of the traction. The client's current position interrupts traction rather than maintains proper countertraction. Holding the weight interrupts the line of pull of the traction and is contraindicated. A client taking colchicine for gout reports weakness, abdominal pain, and nausea and vomiting for the past 2 days. How should the nurse interpret these symptoms? a. therapeutic effects of the meds b. signs of toxicity c. expected side effects d. an allergic response - CORRECT ANSWER b. rationale: the symptoms described are signs of toxicity. The client should be instructed to stop the medication and be seen for follow-up treatment. The expected therapeutic effect of colchicine is to diminish the joint pain associated with the acute attack. The combo of symptoms is too severe to be expected as side effects of the medication. The symptoms are not consistent with an allergic response. A client in skeletal traction for a right femur fracture reports pain in the affected limb. After assessing that the right foot is pale without a pulse, what should the nurse do next? Select all apply. a. Ensure that the leg is not raised above heart level b. Administer analgesics as ordered c. release the traction d. recheck the pulse in an hour e. document the findings and notify the healthcare provider - CORRECT ANSWER a., e. rationale: pain and absent pulse indicate impaired circulation to the affected limb, which requires tx to prevent damage to nerves and tissues, and necrosis requiring loss of limb (worst case). The nurse needs to ensure that the leg is not above heart level so no further damage occurs. Findings should always be documented and the healthcare provider needs to be notified of the complication, so further medical assessment and treatment can be done. Pain caused by tissue ischemia will not be relieved by analgesics. Releasing the traction would be contraindicated. Rechecking the pulse in an ours is delayed and also fails to assist the client. An 87-year-old underweight client who sustained a right hip fracture asks the nurse how long it will take for the fracture to heal. The nurse's response includes consideration of which client factor that influences the rate of bone healing? a. frequency of physical therapy b. age of the client c. weight of the client d. early ambulation - CORRECT ANSWER b. rationale: age, site of the fracture, and blood supply to the affected area all affect the rate of bone healing. Younger and healthy clients will have faster bone healing than older adults and those with chronic illnesses. Although physical therapy will assist in mobility, it does not directly enhance bone healing. The weight of the client, unless accompanied by malnutrition, does not have a direct bearing on bone healing. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - CORRECT ANSWER Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? - CORRECT ANSWER Creatinine 1.9 mg/dL A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? - CORRECT ANSWER Abdominal cramps A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? - CORRECT ANSWER Encourage abdominal breathing. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - CORRECT ANSWER 0.7 A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? - CORRECT ANSWER Thrombophlebitis A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? - CORRECT ANSWER Increase intake of fiber-rich foods. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? - CORRECT ANSWER Perform pin site care daily. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - CORRECT ANSWER Loosen clothing around the client's neck. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? - CORRECT ANSWER Encourage the client to complete ADLs. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Avoid liquids at mealtimes. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? - CORRECT ANSWER Decreased shortness of breath A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? - CORRECT ANSWER Rephrase client instructions when not understood. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? - CORRECT ANSWER Pinch the NG tube. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? - CORRECT ANSWER Encourage weight-bearing exercises. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? - CORRECT ANSWER "I don't cross my legs anymore." A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? - CORRECT ANSWER "I will have my HbA1c checked twice per year." A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? - CORRECT ANSWER Dispose of radiation implants in a lead container. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? - CORRECT ANSWER Allow for 30 min of rest before meals. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? - CORRECT ANSWER Pulmonary embolism A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? - CORRECT ANSWER "You are at risk for infertility with this infection, regardless of treatment." A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - CORRECT ANSWER Keep the client in a side-lying position. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? - CORRECT ANSWER Initiate oxygen at 4 L/min via nasal cannula. A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER "This type of insulin should be given at the same time every day." A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? - CORRECT ANSWER Bradycardia A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? - CORRECT ANSWER Bradycardia A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? - CORRECT ANSWER Stop the infusion. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? - CORRECT ANSWER History of treatment for blood clots A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? - CORRECT ANSWER Change the sheepskin liner weekly. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? - CORRECT ANSWER Dysrhythmia A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? - CORRECT ANSWER Small liquid stools A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? - CORRECT ANSWER Stop the medication infusion. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? - CORRECT ANSWER Apply a mask on the client if transport is needed. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? - CORRECT ANSWER "Avoid bending your hips more than 90 degrees." A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? - CORRECT ANSWER "I understand that testicular cancer is painless." A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? - CORRECT ANSWER Intra-abdominal bleeding A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? - CORRECT ANSWER Keep a sheepskin pad between the client's extremity and the CPM. A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? - CORRECT ANSWER Lack of sensation between the first and second toes A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? - CORRECT ANSWER "I should call my doctor if my ankles swell." A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Remind the client to avoid watching her feet when walking. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? - CORRECT ANSWER Red macular rash A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? - CORRECT ANSWER "Limit contact with large groups of people." A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? - CORRECT ANSWER "Consume foods low in sodium." A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? - CORRECT ANSWER Urinary retention A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? - CORRECT ANSWER Position pillows between the bony prominences. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? - CORRECT ANSWER "You should have a pneumococcal immunization every 10 years." A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Apply cold packs to the inflamed joints. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.) - CORRECT ANSWER Hyperactive bowel sounds A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? - CORRECT ANSWER Lemon juice A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? - CORRECT ANSWER Dyspnea A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? - CORRECT ANSWER Maintain abduction of the client's right leg while in bed. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? - CORRECT ANSWER Encourage the client to use an incentive spirometer every hour while awake. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? - CORRECT ANSWER Recommend a referral for a speech language pathologist. A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? - CORRECT ANSWER Keep the skin dry and free of perspiration. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? - CORRECT ANSWER Hgb 11 g/dL A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Avoid stopping this medication suddenly. A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) - CORRECT ANSWER c A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? - CORRECT ANSWER Visitors must don a gown and gloves prior to entering the client's room. A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? - CORRECT ANSWER olive oil A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? - CORRECT ANSWER Have a designated stethoscope in the client's room. A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? - CORRECT ANSWER Minimize the time the head of the bed is elevated. A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? - CORRECT ANSWER BUN A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? - CORRECT ANSWER Prealbumin 12 mg/dL A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? - CORRECT ANSWER Instruct the client to swish the medication in her mouth. A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? - CORRECT ANSWER Administer epinephrine. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? - CORRECT ANSWER "Tell me more about the way you are feeling." A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? - CORRECT ANSWER Dangle the extremities off the side of the bed. A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER "I should wait at least 2 hours after eating before going to bed." A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? - CORRECT ANSWER Report purulent drainage to the provider. Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take? - CORRECT ANSWER Reschedule the FBS test for early the next morning. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? - CORRECT ANSWER Determine the client's understanding of the procedure. A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? - CORRECT ANSWER Irregular borders A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? - CORRECT ANSWER Decreased potassium A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? - CORRECT ANSWER Ventilate with 100% oxygen. A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group? - CORRECT ANSWER Herpes zoster A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? - CORRECT ANSWER Obtain a raised toilet seat. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? - CORRECT ANSWER Onset of nausea A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? - CORRECT ANSWER Combination oral contraceptives A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? - CORRECT ANSWER Eat several, small-portioned meals daily. A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? - CORRECT ANSWER Determine the client's daily elimination habits. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? - CORRECT ANSWER Give the client liquids with increased viscosity. A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - CORRECT ANSWER Ceftriaxone A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? - CORRECT ANSWER Listen to soft music before sleeping. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) - CORRECT ANSWER "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? - CORRECT ANSWER Mask A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? - CORRECT ANSWER The client stops the nurse and asks for pain medication. A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? - CORRECT ANSWER Palpate the abdomen. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? - CORRECT ANSWER Decreases pain during urination 1. A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery A) Serious drainage from the incision B) WBC count of 15,000/mm C) Temperature of 37.2 C (99 F) D) Urine output of 400 mL over the past 8 hr - CORRECT ANSWER B) WBC count of 15,000/mm A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first? A) Obtain the client's temperature. B) Observe for phantom pain. C) Measure urinary output. D) Check the incisional dressing. - CORRECT ANSWER D) Check the incisional dressing. The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding. A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching? A) "I will need to take the medication until my thyroid function returns to normal." B) "The medication should be taken before I eat breakfast every morning." C) "The medication might lower my blood sugar." D) "I will take the medication with an antacid if it gives me heartburn." - CORRECT ANSWER B) "The medication should be taken before I eat breakfast every morning." The nurse should instruct the client to take levothyroxine at the same time each day, preferably 1 hr before breakfast. A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect? A) Muscle spasticity B) Tremors at rest C) Ptosis D) Ascending paralysis - CORRECT ANSWER A) Muscle spasticity Muscle spasticity is a manifestation of multiple sclerosis. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication? A) "I have been sleeping less since I started the medication." B) "I have gained 3 pounds since my last appointment." C) "My bowel movements have become more frequent." D) "I urinate more often than before." - CORRECT ANSWER B) "I have gained 3 pounds since my last appointment." Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective. A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? A) "You should thaw frozen meat at room temperature." B) "You should use paprika as a seasoning for your food." C) "You should place your toothbrush in hydrogen peroxide overnight." D) "You should use a glycerin-based soap while bathing." - CORRECT ANSWER C) "You should place your toothbrush in hydrogen peroxide overnight." Clients who are receiving chemotherapy should clean their toothbrushes by soaking them overnight in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection. A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following client statements indicates an understanding of the teaching? A) "I inhaled the infected droplets that were in the air." B) "I must have touched someone who had TB." C) "I probably caught this disease from a mosquito bite." D) "I developed TB from having unprotected sex." - CORRECT ANSWER A) "I inhaled the infected droplets that were in the air." TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching. A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? A) Observe for impulsive behavior. B) Approach the client from the right side. C) Use simple verbal cues when directing tasks. D) Place the client in low-Fowler's position during meals. - CORRECT ANSWER C) Use simple verbal cues when directing tasks. The nurse should expect a client who experiences a left hemispheric stroke to manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication. A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP? A) Allow the weights to hang freely. B) Release the tension of the ropes. C) Remove the weights when rewrapping bandages. D) Manually lift the weights when moving the client up in bed. - CORRECT ANSWER A) Allow the weights to hang freely. The nurse should instruct the AP to allow the weights to hang freely and to refrain from bumping the weights. Skeletal traction maintains alignment of fractured bones through the use of counterweights. If these weights rest on the floor or another object, they do not maintain the counterbalance necessary to maintain the alignment of the fracture, which can result in client injury or pain. A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect? A) Clamp the urethral catheter for 30 min. B) Place the urethral catheter drainage bag at the client's heart level. C) Slow the bladder irrigation flow rate. D) Irrigate the urethral catheter with 0.9% sodium chloride. - CORRECT ANSWER D) Irrigate the urethral catheter with 0.9% sodium chloride. The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging? "I sweat more than I used to." "Sometimes I can't remember my kids' names." "I seem to have more loose stools than I used to." "My food tastes bland even after I add seasoning." - CORRECT ANSWER "My food tastes bland even after I add seasoning." As clients age, their sense of smell decreases, causing a secondary decrease in taste. A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take? A) Check for kinks in the NG tube B) Increase the IV fluid rate C) Provide ice chips D) Administer an antiemetic - CORRECT ANSWER A) Check for kinks in the NG tube The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the priority action is to check the NG tube to determine if the tube is kinked, which can interfere with the suctioning function and result in nausea. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? A) "I will add a banana to my morning cereal." B) "I will decrease my intake of carbohydrates." C) "I will limit my daily intake of protein." D) "I will season my foods with a salt substitute." - CORRECT ANSWER C) "I will limit my daily intake of protein." The client should decrease his intake of protein to slow the progression of kidney failure. Therefore, the nurse should identify this statement as an understanding of the teaching. A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify the client's injury occurred in which of the following lobes of the brain? - CORRECT ANSWER A is correct. Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully. A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse? A) Reported pain level of 6 on a scale of 0 to 10 B) Urinary output of 110 mL in the past 4 hr C) Temperature of 38.0º C (100.4º F) D) Oxygen saturation of 88% - CORRECT ANSWER D) Oxygen saturation of 88% A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client? A) Semi-Fowler's with knees flexed B) Orthopneic C) Dorsal recumbent D) Prone with legs straight - CORRECT ANSWER A) Semi-Fowler's with knees flexed Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back and relieve pressure on the nerves. A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury? A) Anorexia B) Hoarseness C) Muscle twitching D) Blurred vision - CORRECT ANSWER C) Muscle twitching A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth. A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? A) Offer the client fresh fruits and vegetables. B) Monitor the client's platelet count daily. C) Limit visitors to healthy adults. D) Apply firm pressure to injection sites. - CORRECT ANSWER C) Limit visitors to healthy adults. A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A) Encourage stimulating activities after dinner. B) Encourage a late afternoon nap. C) Offer a small snack at bedtime. D) Offer hot chocolate at bedtime. - CORRECT ANSWER C) Offer a small snack at bedtime. The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep. A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber? A) ½ cup cooked kidney beans B) ½ cup raw cauliflower C) 1 cup cucumber with peel D) 1 cup parboiled brown rice - CORRECT ANSWER A) ½ cup cooked kidney beans The nurse should recommend kidney beans as the best source of fiber because ½ cup contains 6.5 g of fiber per serving. A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include? A) Limit protein in daily meal plan. B) Use a bronchodilator 1 hr before meals. C) Drink beverages at the end of meals. D) Lie down for 1 hr after meals. - CORRECT ANSWER C) Drink beverages at the end of meals. The client should drink beverages at the end of meals, rather than during meals, to prevent shortness of breath while eating. This also prevents early satiety and promotes adequate nutrient intake during the meal. A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take? A) Massage the area. B) Remove the weights. C) Loosen the ropes. D) Reposition the client. - CORRECT ANSWER D) Reposition the client. When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed. A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction? A) Decreased lipase B) Decreased erythrocyte sedimentation rate (ESR) C) Elevated creatinine D) Elevated troponin - CORRECT ANSWER D) Elevated troponin Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication that the client is experiencing a myocardial infarction. A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? A) The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5% to 10%. B) An HbA1c level below the expected reference range indicates poor glucose control. C) HbA1c results measure glucose control for the prior 3 months. D) HbA1c testing is used to provide a diagnosis of diabetes mellitus. - CORRECT ANSWER C) HbA1c results measure glucose control for the prior 3 months. HbA1c testing reflects average overall glucose control over a 3-month period. The nurse should inform the client that HbA1c testing is the best measure of long-term glucose control. A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care? A) Check neurovascular status on the extremity every 8 hr. B) Have the client perform incentive spirometry every 4 hr. C) Keep an abduction pillow between the client's legs. D) Maintain the client on bed rest until the third postoperative day. - CORRECT ANSWER C) Keep an abduction pillow between the client's legs. The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery. A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? A) Withdraw both types of insulin and then add 0.2 mL of air to the syringe. B) Gently shake the NPH insulin prior to withdrawing the dose. C) Withdraw the regular insulin before withdrawing the NPH insulin. D) Inject air into the NPH vial after withdrawing regular insulin. - CORRECT ANSWER C) Withdraw the regular insulin before withdrawing the NPH insulin. The nurse should instruct the client to withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin. A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take? A) Educate the client about choosing low-fat, low-cholesterol foods. B) Have the client flex hips and knees when lying in bed. C) Encourage the client to wear elastic support hose during the day time. D) Instruct the client to use an electric heating pad. - CORRECT ANSWER A) Educate the client about choosing low-fat, low-cholesterol foods. The nurse should educate the client about a low-fat, low-cholesterol diet, which is prescribed for clients who have atherosclerosis. This diet can also aid in weight reduction, which can improve activity tolerance. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? A) Measure rectal temperature every 4 hr. B) Remind the client to cough as needed. C) Use a turn sheet to reposition the client. D) Apply wrist restraints. - CORRECT ANSWER C) Use a turn sheet to reposition the client. The nurse should change the client's position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client provides the nurse with the ability to better control the client's movement and alignment. The nurse should instruct the client to exhale during the position change to prevent an increase in ICP. A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? A) "I drink bottled water." B) "I eat a salad bar for lunch." C) "I like to eat steak cooked medium." D) "I put plenty of pepper on my soft-boiled eggs" - CORRECT ANSWER A) "I drink bottled water." To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria. A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first? A) Verify the client has given informed consent. B) Administer preoperative medication. C) Mark the location of the pedal pulses. D) Have the client void. - CORRECT ANSWER A) Verify the client has given informed consent. The greatest risk to the client in this situation is performing an unauthorized invasive procedure. Therefore, the first action the nurse should take is to verify that the client has given informed consent. If documentation of informed consent is not on the client's medical record, the nurse should withhold medications, which can alter the client's consciousness until consent is obtained. A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make? A) "The kidneys' ability to filter urine is decreased." B) "The tumor causes obstruction of urine from the urethra." C) "The cancer results in hormonal changes, which affect urination." D) "The protein-specific antigen in your blood is decreased." - CORRECT ANSWER B) "The tumor causes obstruction of urine from the urethra." As a prostate tumor grows, it compresses the urethra, resulting in obstructed urine flow. A nurse is reinforcing discharge teaching for a client who has a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching? A) "I will notify my dentist about this procedure." B) "I will take an enteric-coated aspirin daily." C) "I will use a firm-bristled toothbrush." D) "I will weigh myself once a week." - CORRECT ANSWER A) "I will notify my dentist about this procedure." The nurse should instruct the client to notify his dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk of endocardial infection. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? A) Sleep on a firm mattress. B) Try jogging in place when joints feel stiff. C) Use a soft chair or recliner for sitting. D) Apply ice packs to painful joints. - CORRECT ANSWER A) Sleep on a firm mattress. A firm mattress or a bed board helps the client maintain joint alignment while sleeping. A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? A) Position the client in Sims' position before electrode placement. B) Ensure that each electrode is dry before application. C) Cleanse the client's skin prior to electrode placement. D) Place the electrodes on the client's abdomen and back. - CORRECT ANSWER C) Cleanse the client's skin prior to electrode placement. The nurse should cleanse the client's skin prior to electrode placement to improve electrode conduction. A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements indicate to the nurse that the client understands the teaching? A) "I will scrub the skin to remove the old skin flakes." B) "I can expect to my leg to be swollen after the cast is removed." C) "I can go back to my usual activities as soon as the cast is off." D) "I will feel vibrations on my leg from the cast cutter." - CORRECT ANSWER D) "I will feel vibrations on my leg from the cast cutter." The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain. A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of the following actions should the nurse take first? A) Administer antituberculosis medication. B) Institute airborne precautions. C) Obtain sputum cultures. D) Auscultate breath sounds. - CORRECT ANSWER B) Institute airborne precautions. The greatest risk from this client is transmitting TB to staff and other clients. Therefore, the first action the nurse should take is to implement airborne precautions. A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching? A) "I should perform pursed-lip breathing exercises before going to bed." B) "When I'm fatigued, I should inhale slowly through pursed lips." C) "Pursed-lip breathing works best for activities like walking up stairs." D) "I will exhale through my nose after breathing in through pursed lips." - CORRECT ANSWER C) "Pursed-lip breathing works best for activities like walking up stairs." The nurse should acknowledge that performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain. A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take? A) Fill the bulb reservoir with 0.9% sodium chloride. B) Allow the Jackson-Pratt drain to hang freely. C) Cut a slit in a gauze sponge and apply it around the tubing insertion site. D) Compress the bulb reservoir and then close the drainage valve. - CORRECT ANSWER D) Compress the bulb reservoir and then close the drainage valve. The nurse should fully compress the bulb reservoir and then replace the valve plug using aseptic technique to establish suction after emptying or activating a Jackson-Pratt drain. A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease? A) Rheumatoid arthritis B) Diabetes mellitus C) Myasthenia gravis D) Crohn's disease - CORRECT ANSWER B) Diabetes mellitus Clients who have diabetes mellitus are at increased risk for developing cardiovascular and peripheral vascular disease due to the changes in the microvasculature resulting from elevated levels of glucose. A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome? A) Place the client in the supine position after meals. B) Administer pancreatic enzymes before meals. C) Encourage the client to drink 240 mL (8 oz) of fluids with meals. D) Offer the client three meals daily. - CORRECT ANSWER A) Place the client in the supine position after meals. The nurse should encourage the client to lie in the supine position for a short time following meals to decrease rapid gastric emptying. A nurse is reinforcing teaching with the parent of a toddler who has type 1 diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. Which of the following information should the nurse include in the teaching? A) Lispro is given once a day. B) Lispro should be given before eating. C) Lispro cannot be given with other insulin. D) Lispro does not cause hypoglycemia. - CORRECT ANSWER B) Lispro should be given before eating. Lispro insulin should be given around mealtime, within 15 min before or after eating. A nurse is reinforcing discharge teaching with a client who has Chron's disease. Which of the following statements should the nurse include in the teaching? A) "Increase your intake of dietary fat." B) "Maintain a low-residue diet." C) "Avoid taking antidiarrheal medications." D) "Plan to weigh yourself weekly." - CORRECT ANSWER B) "Maintain a low-residue diet." The nurse should instruct the client to maintain a low-fiber, low-residue diet, which helps control pain and inflammation in the small intestine and reduces episodes of diarrhea. A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects? A) Bradycardia B) Tremors C) Cough D) Hyperglycemia - CORRECT ANSWER C) Cough Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough. Therefore, the nurse should monitor the client for this adverse effect. A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? A) Elevated serum amylase level B) Hypertension C) Bradycardia D) Decreased leukocyte count - CORRECT ANSWER A) Elevated serum amylase level The nurse should anticipate an elevation in the client's serum amylase level due to injury of the pancreatic cells. A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? A) Give the dose as prescribed. B) Use a different route to administer the medication. C) Administer half of the prescribed dose. D) Withhold the dose. - CORRECT ANSWER D) Withhold the dose. The nurse should withhold the digoxin dose for an apical pulse less than 60/min and notify the provider. Digoxin slows the heart rate, so administering the dose can cause harm to the client. A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect? A) Seeing halos around artificial lights B) Distorted central vision of the eyes C) Colored spots before the visual fields D) Spontaneous tearing of the eyes - CORRECT ANSWER B) Distorted central vision of the eyes Macular degeneration results in a distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center. A nurse is caring for a client who has a new cast on her left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? A) Compartment syndrome B) Fat embolism C) Deep-vein thrombosis D) Osteomyelitis - CORRECT ANSWER A) Compartment syndrome Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities and a delay in capillary refill, and without immediate treatment, can cause nerve damage and necrosis. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider? A) Absent gag reflex B) Blood-tinged mucus C) Diminished breath sounds D) Oxygen saturation 95% - CORRECT ANSWER C) Diminished breath sounds Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse should report this finding to the provider for further evaluation of the client. A nurse is caring for a client who begings to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. - CORRECT ANSWER Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity? A) Potassium chloride B) Famotidine C) Levothyroxine D) Furosemide - CORRECT ANSWER D) Furosemide The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take? A) Prepare for intubation of the client. B) Administer opioid medication. C) Administer oxygen via nasal cannula. D) Place the client in low-Fowler's position. - CORRECT ANSWER C) Administer oxygen via nasal cannula. The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed. A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? A) Avoid weight-bearing until healing of the hip incision is complete. B) Cross legs intermittently several times a day. C) Lean forward to change positions when sitting in a chair. D) Maintain hip flexion to 90° or less when sitting. - CORRECT ANSWER D) Maintain hip flexion to 90° or less when sitting. A client who has had a cemented total hip arthroplasty should maintain hip flexion to 90° or less when sitting to prevent hip dislocation. A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? A) Pleural friction rub B) Wheezes C) Vesicular D) Crackles - CORRECT ANSWER B) Wheezes The nurse should identify the breath sound auscultated as wheezes. These are high-pitched, musical sounds that occur as air passes through narrowed airways, such as when a client is experiencing an asthma attack. A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care? A) Keep bed linens off of the affected areas. B) Position a heat lamp over the lower extremities. C) Apply warm, moist compresses to the affected areas. D) Initiate droplet isolation precautions. - CORRECT ANSWER A) Keep bed linens off of the affected areas. The nurse should keep bed linens off of the affected areas using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions. A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin? A) Store unopened insulin vials in the freezer for up to 1 month. B) Opened insulin can be stored on a cool countertop away from light. C) Roll discolored insulin gently to mix it before use. D) Use refrigerated insulin immediately after removing it from the refrigerator. - CORRECT ANSWER B) Opened insulin can be stored on a cool countertop away from light. The nurse should inform the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight. A nurse is caring for a client who is receiving a continuous tube feeding of 60mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? - CORRECT ANSWER If there are 1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is 864. A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? A) Metoprolol B) Methimazole C) Furosemide D) Prednisone - CORRECT ANSWER D) Prednisone Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis. A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome? A) Reduced cough B) Diminished headache C) Relaxed muscles D) Decreased peripheral edema - CORRECT ANSWER B) Diminished headache Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor the client for a diminished headache as an expected outcome of the medication. A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider? A) Hemoglobin 13 g/dL B) Blood pressure 110/55 mm Hg C) Heart rate 120/min D) Potassium 3.6 mEq/L - CORRECT ANSWER C) Heart rate 120/min The client's heart rate of 120/min is above the expected reference range and indicates the client's dehydration has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement. A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A) A client who had a colectomy 2 days ago and has a nasogastric tube, Jackson-Pratt drain, and indwelling urinary catheter B) A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night C) A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to continuous suction D) A client who has pneumonia and an oral temperature of 38.7º C (101.7º F) - CORRECT ANSWER B) A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night When using the urgent vs. nonurgent approach to client care, the nurse determines to first see the client who has mental confusion and is getting out of bed without assistance. The client is experiencing manifestations of dehydration that can cause injury due to falls. Therefore, the nurse should see this client first. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain? A) Semi-Fowler's B) Supine with lower extremities elevated C) Upright, leaning forward D) Side-lying with knees bent - CORRECT ANSWER C) Upright, leaning forward The nurse should plan to place a client who has pericarditis in an upright position, leaning forward, to facilitate breathing and decrease pain. A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? A) Place the client in Fowler's position. B) Obtain the client's blood pressure. C) Dangle the client's legs at the bedside. D) Apply nonskid slippers. - CORRECT ANSWER B) Obtain the client's blood pressure. The greatest risk to the client is postural hypotension due to decreased blood volume following surgery. Therefore, the first action the nurse should take is to obtain the client's baseline blood pressure to determine whether it is safe to have the client get out of bed. A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective? A) Adventitious lung sounds B) Decrease in exertional dyspnea C) Respiratory rate of 26/min while sitting in a chair D) Elevation of the head of the bed is required to sleep - CORRECT ANSWER B) Decrease in exertional dyspnea A decrease in exertional dyspnea indicates the antibiotics are resolving the infection and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the client. A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? A) Encourage the client to ambulate. B) Administer an antipyretic medication. C) Notify the charge nurse of the client's BUN level. D) Keep the temperature in the client's room warm. - CORRECT ANSWER C) Notify the charge nurse of the client's BUN level. The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal function. The nurse should notify the charge nurse of this finding and anticipate interventions to restore the client's fluid volume. A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take? A) Secure the drainage tube to the client's bedding. B) Wear sterile gloves to empty the drainage system. C) Cut an absorbent gauze dressing to fit around the drainage tube. D) Cleanse the drainage plug with alcohol swabs. - CORRECT ANSWER D) Cleanse the drainage plug with alcohol swabs. The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system. A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb). Which of the following statements by the client indicates an understanding of the teaching? A) "I should insert the needle at a 90-degree angle." B) "I should give my shot in my belly tissue." C) "I will pull back on the syringe plunger to look for blood before I push the medication in." D) "I will use the side of my hand to pull my skin to the side prior to administering the insulin." - CORRECT ANSWER B) "I should give my shot in my belly tissue." Clients who have low body weights can have very little subcutaneous tissue. Therefore, the nurse should instruct the client to administer the medication in the upper abdomen for proper absorption. A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take? A) Blow cool air into the cast using a blow dryer on a cool setting. B) Obtain a prescription for pregabalin. C) Ask the provider to bivalve the cast. D) Provide the client with a tongue blade to rub the skin under the cast. - CORRECT ANSWER A) Blow cool air into the cast using a blow dryer on a cool setting. Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin. A nurse is contributing to the plan of care for a client who has just transferred to the medicalsurgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? A) Massage both lower extremities to promote comfort. B) Begin the client on a regular diet when the gag reflex returns. C) Encourage the client to use the incentive spirometer every 4 hr while awake. D) Assist the client to change positions at least every 2 hr. - CORRECT ANSWER D) Assist the client to change positions at least every 2 hr. The nurse should assist the client to change positions at least every 2 hr to promote return of respiratory function following anesthesia and prevent atelectasis and pneumonia. A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team members should the nurse recommend a referral prior to initiating oral intake for the client? A) Occupational therapist B) Speech-language pathologist C) Physical therapist D) Case manager - CORRECT ANSWER B) Speech-language pathologist The nurse should recommend a referral for a speech-language pathologist to evaluate the client's ability to safely swallow. A client who has had a CVA is at increased risk for dysphagia and aspiration of fluids, food, and medications. The speech-language pathologist should conduct a swallowing study to determine the client's risk for aspiration and provide teaching to the client regarding swallowing techniques. A nurse is preparing to inset a double-lumen gastric (Salem) sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select? Dark blue Light blue ball White swirly Red and yellow hahahah sorry i dont know how to upload the pics - CORRECT ANSWER ANSWER A The wrapped up white cord with the blue tip A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend to include in the pamphlet? A) The number of sexual partners does not affect the risk for STIs. B) Oral contraceptive use decreases the risk for STIs. C) Men seek treatment for STIs later than women. D) Women have a higher risk of contracting STIs than men. - CORRECT ANSWER D) Women have a higher risk of contracting STIs than men. The nurse should include that oral contraceptive use, prolonged contact with male secretions, and increased cervical permeability during hormone fluctuations increase a woman's risk of acquiring STIs. A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? A) "I am allergic to shrimp." B) "I am allergic to latex balloons." C) "I had a tuberculosis skin test 2 days ago." D) "I had a low fever this morning." - CORRECT ANSWER D) "I had a low fever this morning." Clients who have a febrile illness should not receive the influenza vaccine. A nurse is reinforcing teaching regarding the use of a continuous passive motion (cpm) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all) A) "Your knee is flexed and extended as prescribed by your provider." B) "The machine is padded with sheep skin." C) "You might have the head of the bed elevated to 45 degrees while using this machine." D) "To use the machine, you must pedal as if you are riding a bike." E) "We will store the CPM machine on the floor under the bed when not in use." - CORRECT ANSWER A) "Your knee is flexed and extended as prescribed by your provider" is correct. The provider will give specific instructions concerning the CPM flexion and extension motion each day. B) "The machine is padded with sheep skin" is correct. Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity. A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. The nurse tells the client to consume foods containing vitamin C when taking the supplement to enhance iron absorption. Which of the following client food choices indicates an understanding of the teaching? A) 1 cup cooked brown rice B) 1 cup boiled broccoli C) 1 cup cottage cheese D) 1 cup cooked kidney beans - CORRECT ANSWER B) 1 cup boiled broccoli The nurse should determine that choosing boiled broccoli indicates an understanding of the teaching because 1 cup contains 101 mg of vitamin C per serving. A nurse in reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? A) Weekly sputum cultures will be needed. B) Household family members should be tested for TB. C) TB is no longer contagious after 2 to 3 days of medication therapy. D) Family members should wear N95 masks when in contact with the client. - CORRECT ANSWER B) Household family members should be tested for TB. The nurse should instruct the client that family members or others who have been in close contact with the client should schedule testing for TB. A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding body image changes. Which of the following should the nurse recognize as a physical change caused by this disease? A) Bronze skin B) Truncal obesity C) Lordosis D) Exophthalmos - CORRECT ANSWER B) Truncal obesity Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns. A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication? A) Frequent colds B) Vitamin deficiency C) Increased urination D) Orthostatic hypotension - CORRECT ANSWER A) Frequent colds The nurse should inform the client that corticosteroids can increase susceptibility to infection by suppressing the immune response. The nurse should instruct the client about infection prevention measures to implement while taking a corticosteroid. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? A) "Place throw rugs on wooden floors at home." B) "Supplement your diet with vitamin E." C) "Swim laps for 20 minutes twice per week." D) "Take calcium supplements with meals." - CORRECT ANSWER D) "Take calcium supplements with meals." The nurse should instruct the client to take calcium carbonate supplements with or following meals to increase absorption and effectiveness. A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures? A) Fasciotomy B) Escharotomy C) Skin grafting D) Hyperbaric oxygen therapy - CORRECT ANSWER B) Escharotomy The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible and the client's oxygenation should improve. A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis? A) "Calcitonin will slow the breakdown of bone in your body." B) "Calcitonin will increase the level of cortisol in your blood." C) "Calcitonin will decrease the amount of calcium you are losing in your urine." D) "Calcitonin will increase the blood flow to your skeletal muscles." - CORRECT ANSWER A) "Calcitonin will slow the breakdown of bone in your body." Calcitonin inhibits osteoclast activity, therefore minimizing bone loss. The medication helps to preserve bone for a client who has osteoporosis. A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? A) Place a "no visitors" sign on the client's door. B) Have the client wear an N95 respiratory mask during transport. C) Initiate droplet precautions for the client. D) Place the client in a negative-pressure airflow room. - CORRECT ANSWER D) Place the client in a negative-pressure airflow room. The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms. A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? A) Granulation tissue is present. B) Urine output is 50 mL/hr. C) Lung sounds are clear. D) Oxygen saturation level is 95%. - CORRECT ANSWER B) Urine output is 50 mL/hr. The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate. A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include in the teaching? A) "Use condoms when lesions are present." B) "Look for lesions that have a wart-like appearance." C)"The virus can be transmitted without lesions present." D) "The lesions resolve in 2 weeks and usually do not recur." - CORRECT ANSWER C)"The virus can be transmitted without lesions present." The nurse should inform the client that viral shedding and spreading of the infection can occur even when lesions are not present. A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure? A) Changes in the client's sputum B) Decreased blood pressure C) Changes in neurological status D) Increased urinary output - CORRECT ANSWER B) Decreased blood pressure Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock. A nurse is reinforcing teaching with a client about testicular self-examiniation. Which of the following instructions should the nurse include in the teaching? A) "Perform testicular self-examination after taking a warm shower." B) "Examine both testicles at the same time." C) "Use the palm of your hand to palpate for abnormalities." D) "Perform testicular self-examination every 6 months." - CORRECT ANSWER A) "Perform testicular self-examination after taking a warm shower." The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes. A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain? A) Methotrexate B) Acetaminophen C) Gabapentin D) Etanercept - CORRECT ANSWER B) Acetaminophen Acetaminophen is a nonopioid analgesic that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics. However, clients should be advised that an overdose of acetaminophen can cause liver damage. A nurse is providing information regarding transmission-based precautions for a client who has C.DIFF to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all) "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." "Use an alcohol-based hand sanitizer after client care." "Wear a face mask when in the client's room." - CORRECT ANSWER "Provide the client with disposable utensils and dishes for meals" is correct. Clients who have C. difficile require contact precautions, which include using disposable utensils and dishes during meals to prevent exposure to contaminants by others. "Leave blood pressure equipment in the client's room" is correct. When using contact precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen. "Clean contaminated surfaces with a bleach solution" is correct. The health care staff should use a bleach solution to clean equipment to prevent transmission of the pathogen. A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching? A) "I will eat more bananas." B) "I will walk for 20 minutes 3 days a week." C) "I will limit my coffee intake." D) "I will take a calcium supplement at bed time." - CORRECT ANSWER C) "I will limit my coffee intake." Coffee contains caffeine, which can cause excretion of calcium through diuretic effects. Clients often drink caffeinated beverages instead of beverages that contain calcium, and caffeine might interfere with the absorption of Vitamin D. Therefore, the nurse should identify this statement as an indication that the client understands the teaching. A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. Which of the following instructions should the nurse include in the teaching? A) "Maintain fat intake of 40 percent of total calories." B) "Have your white blood cell count checked." C) "Sustain an HDL level of 25 milligrams per deciliter." D) "Add oily fish to your diet twice weekly." - CORRECT ANSWER D) "Add oily fish to your diet twice weekly." The nurse should reinforce teaching about dietary changes to manage coronary artery disease, such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice weekly or taking a fish oil supplement daily. A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion? A) Restrict visitors to three at a time. B) Avoid touching the client during care. C) Encourage reminiscence of past experiences. D) Give the client multiple options for daily events. - CORRECT ANSWER C) Encourage reminiscence of past experiences. The nurse should encourage reminiscence of past experiences to reduce the client's confusion. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? - CORRECT ANSWER Pain that increases with passive movement A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? - CORRECT ANSWER My joints ache because I have Lyme disease A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - CORRECT ANSWER 24 A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - CORRECT ANSWER place a pressure bag around the flush solution A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? - CORRECT ANSWER Report of sore throat A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? - CORRECT ANSWER Facial butterfly rash A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? - CORRECT ANSWER Place tach tray at the bedside A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? - CORRECT ANSWER Low urine specific gravity A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? - CORRECT ANSWER You will need to stay still in the bed during each treatment session." A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? - CORRECT ANSWER Encourage the client to take deep breaths after the procedure A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? - CORRECT ANSWER Slow the infusion rate A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? - CORRECT ANSWER Hemodialys is something required following surgery A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? - CORRECT ANSWER Constipation A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? - CORRECT ANSWER I will refer you to community resources that can provide support A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? - CORRECT ANSWER Client reports back pain A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Create complete outfits and allow the client to select one each day A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? - CORRECT ANSWER "I can speak to the provider about incorporating acupuncture into your treatment plan." A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? - CORRECT ANSWER Stridor A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? - CORRECT ANSWER Troponin I 8 ng/mL A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? - CORRECT ANSWER Check for the type and number of units of blood to administer A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? - CORRECT ANSWER WBC count 2,000 A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? - CORRECT ANSWER Numbness can occur along the inside of the affected arm A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) - CORRECT ANSWER Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? - CORRECT ANSWER Scan the environment by turning your head from side to side." A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? - CORRECT ANSWER Bubbling in the water seal chamber has ceased. A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER I will use an electric razor to shave A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? - CORRECT ANSWER Sedimentation rate A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? - CORRECT ANSWER Avocados A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? - CORRECT ANSWER Glucose 272 A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? - CORRECT ANSWER Regular insulin 20 units IV A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - CORRECT ANSWER A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Drink 240 mL (8 oz) of water after administration. A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? - CORRECT ANSWER This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER "I will avoid direct exposure to the sun." A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? - CORRECT ANSWER Airborne A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - CORRECT ANSWER Serum creatinine A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) - CORRECT ANSWER Calf pain Numbness in the arms Intense headache A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? - CORRECT ANSWER Use crutches with rubber tips. A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? - CORRECT ANSWER "Ibuprofen can cause gastrointestinal bleeding in older adult clients." A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? - CORRECT ANSWER Heart rate 52/min A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - CORRECT ANSWER Dyspnea A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? - CORRECT ANSWER "Ginkgo biloba can cause an increased risk for bleeding." A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) EXHIBIT - CORRECT ANSWER BUN A nurse is receiving report on a client who is postoperative following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) - CORRECT ANSWER A )Neck A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? - CORRECT ANSWER Warfarin A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? - CORRECT ANSWER Hair loss on the lower legs A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Change position every hour. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? - CORRECT ANSWER Alternate application of heat and cold to the affected joints. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? - CORRECT ANSWER Restlessness A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? - CORRECT ANSWER Extremity cool upon palpation A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? - CORRECT ANSWER Temperature 38.9° C (102° F) A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? - CORRECT ANSWER Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? - CORRECT ANSWER A tingling sensation replacing the pain A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Consume at least 30 g of fiber daily. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER "I will take my temperature once a day." A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? - CORRECT ANSWER INR 2.5 A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - CORRECT ANSWER AdminiSTER o2 Initiate IV therapy Insert an NG tube Administer ranitidine A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio button to listen to the clip.) - CORRECT ANSWER Pericardial friction rub A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? - CORRECT ANSWER Prednisone A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? - CORRECT ANSWER Walk for 30 min four times per week. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? - CORRECT ANSWER "This identifies if the pacemaker cells of my heart are working properly." A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? - CORRECT ANSWER Scan the bladder with a portable ultrasound. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - CORRECT ANSWER The client's heart rate increases. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? - CORRECT ANSWER Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? - CORRECT ANSWER Heart rate 110/min A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? - CORRECT ANSWER Bathe the client using chlorhexidine solution. FLAG A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? - CORRECT ANSWER Distended neck veins A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? - CORRECT ANSWER Flex the foot every hour when awake. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? - CORRECT ANSWER Applying oxygen via face mask A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? - CORRECT ANSWER Check the client's neurologic status. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? - CORRECT ANSWER Keep the client occupied with a manual activity. A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? - CORRECT ANSWER "Discontinuing with the treatments is your choice if it is your wish to do so." A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? - CORRECT ANSWER Place personal items, such as pictures, at the client's bedside. A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? - CORRECT ANSWER Holding breath for 10 seconds after inhaling A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? - CORRECT ANSWER Low back pain and apprehension A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.) - CORRECT ANSWER Loosen restrictive clothing on the client. Prepare to suction the client's airway. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? - CORRECT ANSWER Crackles heard on auscultation A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER "I will eat more high-fiber foods." A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? - CORRECT ANSWER "I will no longer floss my teeth after brushing my teeth." A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? - CORRECT ANSWER Irrigate the indwelling urinary catheter. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER "Increase fiber intake to avoid constipation." A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? - CORRECT ANSWER Document that depolarization has occurred. FLAG A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? - CORRECT ANSWER Contact the provider to clarify the prescription. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with longterm mechanical ventilation? - CORRECT ANSWER Stress ulcers A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? - CORRECT ANSWER PaCO2 56 mm Hg A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Family members in the household should undergo TB testing. A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? - CORRECT ANSWER Compress the drain reservoir after emptying. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? - CORRECT ANSWER Keep a lead-lined container in the client's room. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? - CORRECT ANSWER BUN 34 mg/dL A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? - CORRECT ANSWER Hypertension Constipation - CORRECT ANSWER Include in teaching: consume at least 30g of fiber daily because it helps produce bulky, soft stools and establish regular bowel patterns RBC administration - CORRECT ANSWER Nurse should stay with the pt for at least 30 min, as most transfusion reactions manifest during the infusion of the first 50-100mL of the product Psyllium (bulk forming laxative) - CORRECT ANSWER Include in teaching: pt should follow each dose with an extra 240mL/8oz of liquid Febrile reaction during blood transfusion - CORRECT ANSWER Nurse should administer an antipyretic such as acetaminophen Verifying NG tube placement after a week - CORRECT ANSWER Check the pH of the aspirated fluid Decreased urine output post-op - CORRECT ANSWER Should be reported because it indicates inadequate kidney function Toe amputation - CORRECT ANSWER Nurse should first assess the color of the extremity because the greatest risk to the pt is injury from impaired tissue perfusion Hepatic encephalopathy - CORRECT ANSWER Lab value decrease that indicates that treatment has been effective is blood ammonia- toxic substances absorbed by the intestines are not broken down, leading to increased ammonia levels Dehydration - CORRECT ANSWER Priority assessment: muscle strength- the greatest risk to the pt is injury from falls Myocardial infarction - CORRECT ANSWER High troponin is an expected finding Climbing stairs on crutches - CORRECT ANSWER Place body weight on the crutches, advance the unaffected leg onto the stair, shift weight from the crutches to the unaffected leg, bring the crutches and the affected leg up to the stair Chronic kidney disease - CORRECT ANSWER Diet: restricted protein diet Stage III pressure ulcer - CORRECT ANSWER Nurse should use hydrocolloid dressing when changing the dressing (Nonadherent gauze dressing is for a wound with little to no drainage so that would no be used) Nephrostomy tube - CORRECT ANSWER Nurse should report if the pt is reporting back pain- it may indicate that the tube is dislodged or clogged Red-tinged urine is an expected finding for the first 12-24hrs following insertion Incision inspection - CORRECT ANSWER Purulent drainage from an incision requires intervention by the nurse- it indicates the presence of infection Acute kidney failure - CORRECT ANSWER Guaifenesin is safe for pt (expectorant) Acetaminophen, calcium carbonate and magnesium hydroxide are not safe Telemetry - CORRECT ANSWER Detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle Full thickness burns - CORRECT ANSWER Nurse should report a GCS of 9 A high temp, a high pain level and a low urine output are expected finding Heroin overdose - CORRECT ANSWER First action nurse should take is to monitor the pt's O2 saturation Anxiety disorder- high HR and RR - CORRECT ANSWER Nursing priority: apply a nonrebreather mask without O2- the greatest risk to the pt is hypocapnia and subsequent development of respiratory alkalosis, therefore the priority is to assist the pt to retain more CO2 Hypokalemia - CORRECT ANSWER S/S to expect: decreased peristalsis Enalapril - CORRECT ANSWER Assess the pt for orthostatic hypotension Low BP and nausea - CORRECT ANSWER Best position is side-lying Blood transfusion in older client with heart failure - CORRECT ANSWER Nurse should monitor for crackles in the lungs, which indicates fluid overload Aortoiliac Disease - CORRECT ANSWER Nurse should first palpate the femoral pulse because the greatest risk is injury from decreased perfusion to the lower extremities Tonic-clonic seizure - CORRECT ANSWER Nurse should prepare to suction the pt's airway (airway can become obstructed) and loosen restrictive clothing so that pt is able to move freely during seizure Nurse should NOT restrain (could cause injury), insert a tongue blade into the mouth (could cause injury) or raise the HOB (pt should be flat on back or turned onto side to prevent aspiration) Shingles - CORRECT ANSWER Pt should be moved to a private room because shingles requires airborne precaution Sealed radiation implant - CORRECT ANSWER Keep a lead-lined container and forceps in the room in case of accidental dislodgment of the implant Premature ventricular contractions - CORRECT ANSWER Nurse should administer Lidocaine, an antidysrhythmic for short-term treatment of ventricular dysrhythmias Fibrocystic breast condition - CORRECT ANSWER Pt should limit intake of sodium add Vitamin C rich foods and take a diuretic as prescribed Pt should continue on birth control pills to decrease estrogen overstimulation Acetylcysteine for COPD - CORRECT ANSWER Indication that med is effective: Pt should be able to cough up secretions more easily (it's a mucolytic agent) Cast to lower extremity - CORRECT ANSWER Nurse should report an increase in the amount of drainage Ciprofloxacin - CORRECT ANSWER Teaching: restrict your caffeine intake while taking this med to reduce CNS stimulation TPN - CORRECT ANSWER If TPN is unavailable, administer 10% dextrose in water until the new bag arrives. TPN solutions have a high concentration of dextrose so the nurse should administer 10% dextrose to avoid a precipitous drop in the pt's blood glucose level Kussmaul respirations - CORRECT ANSWER Expected with respiratory acidosis Right hemispheric CVA - CORRECT ANSWER Nurse should expect to find visual spatial deficit, left hemianopsia and one-sided neglect Intra-arterial radial catheter - CORRECT ANSWER Nurse should check capillary refill distal to the catheter insertion sit to monitor for impaired circulation Mannitol - CORRECT ANSWER Adverse effect is headache which should be reported to the provider because it indicates that pt is experiencing a rebound increase in ICP Biliary colic - CORRECT ANSWER Nurse should administer hydromorphone (biliary colic is pain caused by gallstones) Omeprazole - CORRECT ANSWER Given for gastric ulcers and works by suppressing gastric acid production It is a proton-pump inhibitor Carvedilol - CORRECT ANSWER Nurse should report weight gain to provider- in a pt with heart failure it indicates that the med is not effective and the condition is worsening Sildenafil (Viagra) - CORRECT ANSWER Pt cannot take while using nitroglycerin because both cause vasodilation and can lead to significant hypotension Total hip arthroplasty - CORRECT ANSWER Nurse should place a pillow between the pt's legs to prevent hip dislocation Nurse should NOT maintain adduction of the legs, encourage ROM up to 120 degrees, keep the hip internally rotated Hypothermia - CORRECT ANSWER Nurse should monitor for hypertension d/t vasoconstriction caused by the hypothermia V-tach: when to defibrillate? - CORRECT ANSWER When pt is unconscious Stage II pressure ulcer - CORRECT ANSWER Nurse should recognize wound is healing with moist, bright red surface in the wound bed. Brown, denatured collagen covering the wound would indicate necrotic tissue Pancreatitis - CORRECT ANSWER Serum calcium should be below expected reference range due to fat necrosis Lumbar puncture - CORRECT ANSWER Following a lumbar puncture, the pt should remain in a dorsal recumbent position IV urography - CORRECT ANSWER Swollen lips are a high priority finding because this indicates that the pt is at greatest risk for an anaphylactic reaction to the contrast media Autonomin dysreflexia - CORRECT ANSWER Bradycardia is a manifestation Allergy testing - CORRECT ANSWER Pt should discontinue prednisone, a glucocorticoid, for up to 4 weeks before allergy testing to avoid suppressing the immune response Supraventricular tachycardia - CORRECT ANSWER Nurse should perform synchronized cardioversion A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? - CORRECT ANSWER Shortening of the right leg ----- The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally. A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? - CORRECT ANSWER Pulmonary embolus ----- Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately. A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? - CORRECT ANSWER Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. ----- The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client up, making sure to maintain proper alignment of the extremity. A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? - CORRECT ANSWER "I should wear elastic stockings on both of my legs." ------ The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as understanding of the teaching. A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? - CORRECT ANSWER "Osteoarthritis can impair a joint on a single side of the body." ------ The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment. A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? - CORRECT ANSWER Report of muscle spasms ----- The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should identify the report of muscle spasms, a physiological need, as the priority client finding. A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? - CORRECT ANSWER Apply cold compresses to the extremity intermittently. ------ Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 min at a time. A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? - CORRECT ANSWER "I will sit upright after taking the medication." ----- A client taking alendronate should sit upright for 30 min after administration to prevent esophageal irritation and ulceration. Therefore, the nurse should identify this statement as indicating an understanding of the teaching. A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? - CORRECT ANSWER "Your provider might prescribe a central catheter line for long-term antibiotic therapy." ------- Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy. A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? - CORRECT ANSWER Fat embolism syndrome ----- The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels. A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse provide the client? - CORRECT ANSWER "Hold your arm against the side of your body." ----- Adduction means to position toward the midline of the body. Therefore, the nurse should provide these instructions to explain the provider's prescription. A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? - CORRECT ANSWER History of anorexia nervosa ----- The nurse should identify anorexia nervosa as a risk factor for osteoporosis. Inadequate protein intake can lead to a decreased bone density, increasing the risk for fractures A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? - CORRECT ANSWER Paresthesias of the extremity ------ The nurse should identify paresthesias as a finding of compartment syndrome. Compartment syndrome involves the compression of nerves and blood vessels in an enclosed space, leading to impaired blood flow and nerve damage. Other findings include numbness, tingling, weakness, and pain that does not respond to medication. A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? - CORRECT ANSWER "This type of pain usually decreases over time as the limb becomes less sensitive." ----- The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain. A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? - CORRECT ANSWER Aspirin ----- Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid interaction between probenecid and salicylate medications. A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? - CORRECT ANSWER Use a hair dryer on a cool setting to blow air into the cast. ------ The nurse should provide relief for the report of itching by blowing cool air into the cast using a hair dryer on a cool setting or an empty 60-mL plunger syringe. A nurse is caring for a client who is postoperative following a total knee arthroplasty and is prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? - CORRECT ANSWER Ask the client to describe the characteristics of the pain. ------ Answering this item requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain. A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following information should the nurse include? - CORRECT ANSWER Cut the wiring if emesis occurs. ----- Inner maxillary fixation involves wiring of the teeth to support the fractured jaw by holding the jawbones together. The wires are left in place until the fracture is healed. To preserve the client's airway, the nurse should instruct the client to have wire cutters available to immediately cut wiring if emesis occurs. The client should return to the provider as soon as possible for rewiring. A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? - CORRECT ANSWER Toes cold to the touch ------ The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch. A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as the treatment for this condition? - CORRECT ANSWER Celecoxib ------ Celecoxib is a type of NSAID, called cyclooxygenase-2 (COX-2) inhibitors, used to relieve some of the manifestations caused by RA in adults. The nurse should identify that the medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? A. Urinary retention B. Administration of celecoxib 24hr ago C. History of immunosuppression D. Administration of levothyroxine 12 hr ago - CORRECT ANSWER *A. Urinary retention* A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A. Position pillows between the bony prominences. B. Check for incontinence every 3 hr. C. Massage reddened areas of the skin. D.Elevate the head of the bed to 45°. - CORRECT ANSWER *A. Position pillows between the bony prominences.* A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? A. Stop the medication infusion. B. Notify the charge nurse. C. Administer a PRN dose of diphenhydramine. D. Follow facility policy for appropriate reporting of the adverse reaction. - CORRECT ANSWER C. Administer a PRN dose of diphenhydramine. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? A. "Your partner will not require treatment for this infection." B. "You can resume sexual activity as soon as you begin treatment." C. "You are at risk for infertility with this infection, regardless of treatment." D. "You will not be at further risk for this infection following treatment. - CORRECT ANSWER C. "You are at risk for infertility with this infection, regardless of treatment." A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? A. Thrombophlebitis B. Infiltration C. Hematoma D. Venous spasms - CORRECT ANSWER D. Venous spasms A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will perform the exam before I shower." B. "I will check my testicles every 6 months." C. "I understand that testicular cancer is painless." D. "I understand that pea-sized lumps are normal." - CORRECT ANSWER C. "I understand that testicular cancer is painless. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? A. Halitosis B. Hemorrhoids C. Rebound tenderness D. Small liquid stools - CORRECT ANSWER D. Small liquid stools A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? A. Mohs surgery is a horizontal shaving of thin layers of the tumor. B. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. C. Mohs surgery is the preferred treatment for melanoma skin cancer. D. Mohs surgery is a palliative treatment for metastatic skin cancer. - CORRECT ANSWER A. Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I should wait at least 2 hours after eating before going to bed." B. "I should eat three meals a day without eating snacks between meals." C. "I should season my food with garlic." D. "I should drink my liquids through a straw." - CORRECT ANSWER A. "I should wait at least 2 hours after eating before going to bed." - CORRECT ANSWER Check IV Stop Infusion Withdraw IV Elevate arm Notify Charge Nurse A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? A. Increase fluid intake. B. Encourage range-of-motion exercises. C. Massage bony prominences. D. Encourage weight-bearing exercises. - CORRECT ANSWER D. Encourage weight-bearing exercises. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all that apply. A. Monitor the insertion site for bleeding. B. Position the affected extremity at a 45° angle. C. Restrict the client's fluid intake. D. Maintain the pressure dressing. E. Check the client's peripheral pulses. - CORRECT ANSWER A. Monitor the insertion site for bleeding. D. Maintain the pressure dressing. E. Check the client's peripheral pulses. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? A. Wound infection B. Pulmonary embolism C. Thrombophlebitis D. Paralytic ileus - CORRECT ANSWER B. Pulmonary embolism A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? A.Rephrase client instructions when not understood. B. Cup hands around the mouth and direct speech toward the client. C. Accentuate vowel sounds by using a higher pitch when speaking. D. Sit to the side of the client and speak instructions into her best ear. - CORRECT ANSWER A.Rephrase client instructions when not understood. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? A. Pruritus B. Nausea C. Urinary retention D. Dyspnea - CORRECT ANSWER D. Dyspnea - CORRECT ANSWER 7mg/10mgx1ml=0.7ml A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A.Consume a low-purine diet. B. Avoid stopping this medication suddenly. C. Use chamomile tea to alleviate insomnia. D. Take this medication on an empty stomach. - CORRECT ANSWER B. Avoid stopping this medication suddenly. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? A. Apply a mask on the client if transport is needed. B. Wear a mask when working within 4 feet of the client. C. Don a gown when visiting with the client. D. Wear an N95 mask when entering the client's room. - CORRECT ANSWER A. Apply a mask on the client if transport is needed. A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? A. Minimize the time the head of the bed is elevated. B Apply a sterile gauze dressing to the site. C. Massage the site with moisturizing lotion. D. Place a donut-shaped cushion under the client's sacral area. - CORRECT ANSWER A. Minimize the time the head of the bed is elevated. A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? A.Scaly patches B. Silvery white plaques C. Irregular borders D. Raised edges - CORRECT ANSWER C. Irregular borders A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? A. Ketchup B. Mayonnaise C. Soy sauce D. Lemon juice - CORRECT ANSWER D. Lemon juice A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? A.Expect decreased sensation for the first postoperative week. B. Avoid lying on the operative side. C. Obtain a raised toilet seat. D. Cross legs at the ankles. - CORRECT ANSWER C. Obtain a raised toilet seat. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? A.Gown B. Mask C. Sterile gloves D. Protective eyewear - CORRECT ANSWER B. Mask A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) A. "I should expect to feel sleepy after using my albuterol inhaler." B. "I never forget to rinse my mouth after using my budesonide inhaler." C. "Between office visits, I keep a record of how many times I use my albuterol inhaler." D. "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler." - CORRECT ANSWER B. "I never forget to rinse my mouth after using my budesonide inhaler." C. "Between office visits, I keep a record of how many times I use my albuterol inhaler." D. "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler." A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? A. Perform pin site care daily. B. Remove the overbed trapeze. C. Remove the boot every 2 hr. D. Keep the weights on a stable, flat surface. - CORRECT ANSWER A. Perform pin site care daily. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.) A. Hyperactive bowel sounds B. Friction rub C. Normal bowel sounds D. Abdominal bruit - CORRECT ANSWER A. Hyperactive. FARTY A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? A.Encourage the client to participate in self-care. B. Assist the client with active range-of-motion exercises. C. Keep the client in a side-lying position. D. Maintain the client's body alignment. - CORRECT ANSWER C. Keep the client in a side-lying position. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? A. Muscle Weakness B. Dysrhythmia C. Abdominal Pain D. Lethargy - CORRECT ANSWER B. Dysrhythmia A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? A. Butter B. Coconut Oil C. Olive Oil D. Shortening - CORRECT ANSWER C. Olive Oil A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? BUN 40 mg/dL Hgb 11 g/dL Urine specific gravity 1.035 Blood glucose 105 mg/dL - CORRECT ANSWER B. Hgb 11 g/dL A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? A. Determine the client's daily elimination habits. B. Administer a suppository to the client 30 min prior to defecation time. C. Offer the client 4 oz of warm prune juice to promote elimination. D. Provide dietary bulk to the client to ease the passage of stool. - CORRECT ANSWER A. Determine the client's daily elimination habits. A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? A.Place moist heat pads on the extremities. B. Perform manual massage of the affected extremities. C. Dangle the extremities off the side of the bed. D. Apply support stockings before getting out of bed. - CORRECT ANSWER C. Dangle the extremities off the side of the bed. A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? A. Drink water before and after each bite. B. Consume foods that are served hot rather than cold. C. Rinse with a glycerin-based mouthwash before meals. D. Eat several, small-portioned meals daily. - CORRECT ANSWER C. Rinse with a glycerinbased mouthwash before meals. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? A. Offer sips of water to the client following oral care. B. Massage the client's lower extremities with lotion every 2 hr. C. Encourage the client to use an incentive spirometer every hour while awake. D. Place one or two pillows beneath the client's knees while he is in bed. - CORRECT ANSWER C. Encourage the client to use an incentive spirometer every hour while awake. A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group? Meningococcal Herpes zoster Human papillomavirus (HPV) Measles, mumps, and rubella (MMR) - CORRECT ANSWER B. Herpes zoster - CORRECT ANSWER D. Consume food low in sodium A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? A. "I should call my doctor if I get a headache." B. "I may develop gastric reflux." C. "I may develop excessive bruising." D. "I should call my doctor if my ankles swell." - CORRECT ANSWER D. "I should call my doctor if my ankles swell." A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? A. "You should have a screening for glaucoma every 5 years." B. "You should have a physical examination every other year." C. "You should have your hearing checked every 2 years." D. "You should have a pneumococcal immunization every 10 years." - CORRECT ANSWER A. "You should have a screening for glaucoma every 5 years." A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? A. Store the CPM machine on the floor when it is not in use. B. Keep a sheepskin pad between the client's extremity and the CPM. C. Check the cycle and range-of-motion settings at least every 12 hr. D. Align the frame joint of the CPM with the middle of the client's calf. - CORRECT ANSWER B. Keep a sheepskin pad between the client's extremity and the CPM. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? A. Restrict the time pregnant women are allowed in the client's room to 15 min. B. Pick up a radiation implant with a double-gloved hand if it becomes dislodged. C. Limit time spent in the client's room to 2 hr during an 8 hr shift. D. Dispose of radiation implants in a lead container. - CORRECT ANSWER D. Dispose of radiation implants in a lead container. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? A.Insert the suction catheter into the tracheostomy. B. Rinse the catheter with sterile 0.9% sodium chloride. C. Ventilate with 100% oxygen. D. Occlude the vent on the catheter for 10 seconds. - CORRECT ANSWER C. Ventilate with 100% oxygen. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? A. Collect a sputum culture. B. Administer ceftriaxone by intermittent IV bolus. C. Initiate oxygen at 4 L/min via nasal cannula. D. Obtain blood cultures. - CORRECT ANSWER B. Administer ceftriaxone by intermittent IV bolus. A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? A. Administer epinephrine. B. Monitor the client's vital signs. C. Monitor the client's oxygen saturation level. D. Administer an antihistamine. - CORRECT ANSWER A. Administer epinephrine. A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? A. Administer doxazosin. B. Palpate the abdomen. C. Insert an indwelling urinary catheter. D. Notify the primary care provider. - CORRECT ANSWER D. Notify the primary care provider. ????? A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? A. Clean the pin sites every 72 hr. B. Use the halo ring to reposition the client when in bed. C. Change the sheepskin liner weekly. D. Tighten the traction bar as needed. - CORRECT ANSWER A. Clean the pin sites every 72 hr. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? A. Allow for 30 min of rest before meals. B. Provide a straw for drinking liquids. C. Serve foods at room temperature. D. Place 2 tsp of food in the client's mouth at a time. - CORRECT ANSWER A. Allow for 30 min of rest before meals. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Elevated sodium Elevated blood pressure Decreased potassium Decreased urine output - CORRECT ANSWER C. Decreased potassium A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? Reduces bacteria in the urinary tract Suppresses urge to void Prevents nerve stimulation to the bladder muscle Decreases pain during urination - CORRECT ANSWER D. Decreases pain during urination A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? Intrauterine device Latex condom Combination oral contraceptives Contraceptive sponge - CORRECT ANSWER C.Combination oral contraceptives A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? A. Administer an analgesic following wound care. B. Irrigate the wound with povidone iodine. C. Cleanse the wound with a cotton-tipped applicator. D. Report purulent drainage to the provider. - CORRECT ANSWER D. Report purulent drainage to the provider. A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Place the client on a low-calorie diet to prevent weight gain. B. Remind the client to avoid watching her feet when walking. C. Use small area rugs in the client's home for traction. D. Instruct the client to take tub baths instead of showers. - CORRECT ANSWER B. Remind the client to avoid watching her feet when walking. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? A. Keep the door of the client's room closed at all times. B. Remove gloves after leaving the client's room. C. Wear a mask when working within 1 m (3 feet) of the client. D. Have a designated stethoscope in the client's room. - CORRECT ANSWER D. Have a designated stethoscope in the client's room A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) EXHIBIT Ceftriaxone Diltiazem Pioglitazone Hydrocodone 5 mg/acetaminophen 500 mg - CORRECT ANSWER A. Ceftriaxone A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? A. Keep the skin dry and free of perspiration. B. Use hot water and antibacterial soap to bathe the client. C. Massage the skin over bony prominences to promote circulation. D. Limit the use of moisturizers on the skin over bony prominences. - CORRECT ANSWER A Keep the skin dry and free of perspiration.. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? Sodium 136 mEq/L Potassium 4.8 mEq/L Creatinine 1.9 mg/dL Calcium 10 mg/dL - CORRECT ANSWER C. Creatinine 1.9 mg/dL A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? Apply cold packs to the inflamed joints. Participate in high-impact exercise. Carry a hand purse rather than a shoulder bag. Sleep on a soft foam mattress. - CORRECT ANSWER a. Apply cold packs to the inflamed joints. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? A. Use a commercial mouthwash before taking the medication. B. Instruct the client to swish the medication in her mouth. C. Discontinue the medication as soon as the lesions are healed. D. Combine the medication with applesauce. - CORRECT ANSWER B. Instruct the client to swish the medication in her mouth. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? A. Provide small, frequent meals. B. Tell the client to extend his neck when swallowing. C. Provide mouth care before meals. D. Give the client liquids with increased viscosity. - CORRECT ANSWER D. Give the client liquids with increased viscosity. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? a. Collaborate with a dietitian. B. Provide nutritional supplements. C. Recommend a referral for a speech language pathologist. d. Inform assistive personnel about proper positioning. - CORRECT ANSWER C. Recommend a referral for a speech language pathologist. - CORRECT ANSWER c A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? Flaccid neck Stooped posture with shuffling gait Red macular rash Masklike facial expression - CORRECT ANSWER C. Red macular rash Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take? A. Offer the client breakfast then repeat the FBS request. B. Reschedule the FBS test for early the next morning. C. Request that the phlebotomist obtain another specimen. D. Ask the laboratory technician to repeat the test on the same specimen. - CORRECT ANSWER B. Reschedule the FBS test for early the next morning. A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Cirrhosis of the liver Hypermotility of the bowel Intra-abdominal bleeding Acute cholecystitis - CORRECT ANSWER c. Intra-abdominal bleeding A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? Report of a dull, throbbing pain Extremities that are cool bilaterally Capillary refill of 3 seconds in the nail beds of the toes - CORRECT ANSWER Lack of sensation between the first and second toes - CORRECT ANSWER c. astopp it A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? Blurred vision Insomnia Bradycardia Weight loss - CORRECT ANSWER c. bRADYCARDIA A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? Take a laxative every morning. Maintain a fluid intake of 1200 mL per day. Limit activity to preserve energy. - CORRECT ANSWER a. Increase intake of fiber-rich foods. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? "I apply rubbing alcohol to my feet every day to prevent infection." "I will wear clean, knee-high wool socks every day to help improve my circulation." "I use hot water bottles to keep my feet warm at night." - CORRECT ANSWER "I don't cross my legs anymore." gONE FORVER - CORRECT ANSWER iN THE BOWELS OF THE ABYSS A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? "This type of insulin should be given at the same time every day." "This insulin can be mixed with short-acting insulin in a single syringe." "This type of insulin can be used in a pump." "This insulin has an increased risk for hypoglycemia." - CORRECT ANSWER A "This type of insulin should be given at the same time every day." A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? The client asks questions each time the nurse stops talking. The client stops the nurse and asks for pain medication. While the nurse is speaking, the client refers to the written materials. A family member who is present asks the client to repeat important points. - CORRECT ANSWER bbb. The client stops the nurse and asks for pain medication. - CORRECT ANSWER d. dRECREASED sON OF A BITCH A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? Use a traction boot to keep the client's right leg internally rotated. Have the client sit in a reclining chair when out of bed. Maintain abduction of the client's right leg while in bed. Encourage the client to perform passive range-of-motion exercises. - CORRECT ANSWER c. ALIENS ABDUCT Maintain abduction of the client's right leg while in bed. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Lower the side rails of the client's bed. Apply wrist restraints to the client. Position the client in the semi-Fowler's position. - CORRECT ANSWER D. Loosen clothing around the client's neck. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? Onset of nausea Increased urinary output Weight loss of 0.9 kg (2 lb) per week Missed dose of the medication - CORRECT ANSWER a. Onset of nausea A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? Instill 10 mL of air through the NG tube. Place the client in the supine position. Irrigate the NG tube. Pinch the NG tube. - CORRECT ANSWER a. Instill 10 mL of air through the NG tube. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? Avoid liquids at mealtimes. Exclude eating starchy vegetables. Avoid eating high-protein meals. Plan to increase intake of sweetened fruits. - CORRECT ANSWER A. Avoid liquids at mealtimes. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? Get out of bed if unable to fall asleep within 60 min. Take a brisk walk before sleeping. Listen to soft music before sleeping. Drink adequate amounts of fluids before sleeping. - CORRECT ANSWER Listen to soft music before sleeping. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. Encourage the client to express his feelings. Allow the client's family to stay with him. Provide music as a distraction. - CORRECT ANSWER a. Determine the client's understanding of the procedure. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates." "The HbA1c test can help detect the presence of ketones in my body." "I will have my HbA1c checked twice per year." "I will plan to fast before I have my HbA1c tested." - CORRECT ANSWER c"I will have my HbA1c checked twice per year." A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? Direct the client to inhale with pursed lips. Set the oxygen therapy at 5 L/min. Instruct the client to lean back when coughing. - CORRECT ANSWER Encourage abdominal breathing. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? Polyuria Abdominal cramps Renal insufficiency Insomnia - CORRECT ANSWER B. Abdominal cramps A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? Five-year history of menopause manifestations Topiramate use for migraine headaches Increased serum cholesterol levels - CORRECT ANSWER History of treatment for blood clots A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? "You may cross your legs in 60 days." "Avoid lying on your operative side." " "You may sleep on a soft mattress." - CORRECT ANSWER Avoid bending your hips more than 90 degrees." A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? Polyuria Constipation Anorexia Bradycardia - CORRECT ANSWER Bradycardia A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors should call prior to visiting the client. Visitors must don a gown and gloves prior to entering the client's room. Visitors need to wear a mask when in close proximity to the client. Visitors may not bring fresh flowers into the client's room. - CORRECT ANSWER Misitors must don a gown and gloves prior to entering the client's room. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Apply hot packs to the client's muscles. Schedule physical therapy in the afternoon. Administer valerian to promote sleep. - CORRECT ANSWER Encourage the client to complete ADLs. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? HbA1c 6% Prealbumin 12 mg/dL WBC 8,000/mm3 Creatinine 0.8 mg/dL - CORRECT ANSWER Prealbumin 12 mg/dL - CORRECT ANSWER tell me mother |=ucking more! A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? Albumin Phosphorus TSH BUN - CORRECT ANSWER hOT CROSS BUNS The nurse is caring for a client who has ulcerative colitis. The nurse knows to monitor for which of the following abnormal lab work? Select all that apply. a. Urine b. Folic acid c. Calcium d. Complete blood count e. Potassium - CORRECT ANSWER c. , d. , e. rationale: Potassium and Calcium - clients with ulcerative colitis are likely to have blood in their stool, decreased amounts of electrolytes due to decreased absorption, and frequent stools leading to elimination of electrolytes before they are absorbed. A CBC is checked for signs of infection and anemia. A nurse is caring for an 86-year-old client who is undergoing surgery for a bladder suspension. The nurse assesses the client's medical history prior to surgery and documents that the client also has arthritis. Which best describes why this information is important? a. The client will have problems transferring from the bed to the operating table b. The client's arthritis medications can interfere with the anesthesia used during surgery c. The client with arthritis has a higher risk for a cardiovascular event d. A client with arthritis will be less likely to have bladder stones - CORRECT ANSWER c. rationale: "The client with arthritis has a higher risk for a cardiovascular event" is correct. When assessing a client who is getting ready for surgery, the nurse must determine if the client has any medical history that could impact the surgery and surgical outcomes. A client with arthritis is at an increased risk for a cardiovascular event, including myocardial infarction. This is similar to a person with diabetes mellitus, or a person ten years older than the age of the surgical candidate. Additionally, the client with arthritis typically presents with fewer complaints of angina and a higher unrecognized cardiovascular disease state. The nurse is caring for a client who has been admitted with an acute exacerbation of ulcerative colitis (UC). Which of the following orders would the nurse question? a. Hemoccult stools b. Labs: CMP, magnesium, phosphorus serum levels c. High protein diet d. 0.9 % normal saline continuous at 75 ml/hr - CORRECT ANSWER c. rationale: A client experiencing an acute exacerbation of UC should be NPO while receiving IV fluids and electrolytes (if needed). Initiating a high-protein diet during this phase would be inappropriate. Once the client is out of the acute phase, this diet is appropriate. The nurse has received report on 4 clients. All clients have pantoprazole ordered. Which client will need this medication first? a. A client with a GI bleed b. A client with a gallstone c. A client with hypovolemia d. A client with a DVT - CORRECT ANSWER a. rationale: Pantoprazole is a proton pump inhibitor that decreases the amount of acid in the GI tract and is used for GERD, GI bleeding and esophageal varicies. The client with a GI bleed will need the medication first, as active bleeding is the priority out of the clients listed. A client has GERD. What changes should the nurse recommend to improve symptoms? Select all that apply. a. Quit drinking alcohol b. Quit smoking c. Raise the foot of the bed 4-6 inches d. Lose weight e. Eat large meals - CORRECT ANSWER a., b., d. rationale: For the management of gastroesophageal reflux disease (GERD), the head of the bed should be raised 4-6 inches, the client should eat small meals, quit smoking, quit drinking, lose weight, and should not eat within four hours of bedtime. Alcohol can cause irritation and increase acid reflux. A nurse is planning medication administration for a client who has all of the following oral medications due at 0900: Calcium carbonate, Codeine, Levetiracetam, Metoclopramide. What is the most appropriate action by the nurse? a. Give Levetiracetam 30 minutes after the others b. Give Metoclopramide 1 hour before the others c. Give Codeine 30 minutes before the others d. Give Calcium carbonate 1 hour after the others - CORRECT ANSWER d. rationale: Calcium carbonate is an antacid, which should always be given 1 hour after other oral medications, otherwise it may impair absorption of those medications. In this case, it would be appropriate to give the other medications at 0830 and the calcium carbonate at 0930. The nurse is caring for a client with poorly controlled GERD. The nurse is providing education regarding foods that can exacerbate the condition. Which of the following would be an appropriate food for this client to eliminate? a. Gluten-containing foods b. Chocolate c. Purine-containing foods like organ meats (liver, kidneys) d. Citrus fruits - CORRECT ANSWER b. rationale: Chocolate contributes to GERD symptoms, because it decreases the tone of the esophageal sphincter which worsens the reflux. Other foods that have this effect include coffee, soda, tea, peppermint, and fried or fatty foods. The nurse is reviewing a medication list for a client who reports they take a medication for gastroesophageal reflux. The client asks the nurse to confirm which medication is used for this condition. Which of the following medications is taken for reflux? a. Fluoxetine b. Famotidine c. Fentanyl d. Furosemide - CORRECT ANSWER b. rationale: "Famotidine" is correct. This is an anti-ulcer H2 histamine blocker, used to treat ulcers, gastroesophageal reflux (GERD), and over-production of acid in the GI system The nurse is caring for a client who is scheduled to be evaluated for possible GERD. The nurse is aware that diagnostic tests for GERD include which of the following? Select all that apply. a. Esophageal impedance pH study b. Esophagram c. Esophageal manometry d. Sigmoid colonoscopy e. Upper endoscopy - CORRECT ANSWER a. , b., c., e. rationale: Esophageal impedance pH study tests to evaluate a client with gastroesophageal reflux disease (GERD) involve the esophagus. An esophageal impedance-pH evaluates the esophagus. Esophagram tests to evaluate a client with gastroesophageal reflux disease (GERD) involve the esophagus. An esophagus evaluates the esophagus. Esophageal manometry tests to evaluate a client with gastroesophageal reflux disease (GERD) involve the esophagus. An esophageal manometry evaluates the esophagus. Upper endoscopy tests to evaluate a client with gastroesophageal reflux disease (GERD) involve the esophagus. An upper endoscopy evaluates the esophagus. The nurse is discharging a client who is newly diagnosed with GERD. Which of the following medication prescriptions indicate the presence of this condition? a. Olanzapine b. Oxycodone c. Omeprazole d. Oxytocin - CORRECT ANSWER c. rationale: "Omeprazole" is correct. This medication is a proton pump inhibitor used to treat GERD and ulcers. The nurse is caring for a client with an intestinal ulcer who takes lansoprazole. The nurse knows to monitor the client for which of the following adverse reactions? Select all that apply. a. Oliguria b. Severe constipation c. Nausea d. Headache e. Diarrhea - CORRECT ANSWER c., d., e. rationale: Lansoprazole is a proton pump inhibitor (PPI) that carries the risk of adverse reactions. These include abdominal pain, headache, nausea, and diarrhea. A client presents to the emergency department with chest pain. The EKG and troponin labs are all within normal limits. Upon reviewing the client's medication list, the nurse notes a medication for acid reflux. Which of the following medications is this? a. Cimetidine b. Clopidogrel c. Captopril d. Cephalexin - CORRECT ANSWER a. rationale: "Cimetidine" is correct. Cimetidine is an anti-ulcer H2 antagonist that treats GERD, ulcers and is used to prevent GI bleeding. When a client with chest pain has negative troponins and a normal EKG, acid reflux is sometimes found to be the cause of the chest pain. A 57-year-old client with peptic ulcer disease is being seen for abdominal pain. Which of the following are assessments for hemorrhage in this client? Select all that apply. a. Monitoring the client's hemoglobin and hematocrit levels b. Recording hourly urinary output c. Administering stool softeners d. Speaking calmly to the client to reduce anxiety e. Assessing for symptoms of dizziness or nausea - CORRECT ANSWER a., e. rationale: "Assessing for symptoms of dizziness or nausea" and "Monitoring the client's hemoglobin and hematocrit levels" are correct. A client with peptic ulcer disease is at higher risk of bleeding because of the disease process. The nurse can assess for bleeding by monitoring hemoglobin and hematocrit levels and assessing for signs of low blood pressure such as dizziness or nausea. The nurse suspects that a client has a duodenal ulcer. Which of the following signs would indicate this condition? a. Pain 1.5-3 hours after eating, relieved by eating b. Hematemesis c. Gnawing, sharp pain 30-60 min after eating d. Pain immediately after eating - CORRECT ANSWER a. rationale: Pain 1.5-3 hours after eating that is relieved by eating is indicative of a duodenal ulcer. Remember, pain 30-60 min after eating is indicative of a gastric ulcer, rather than a duodenal ulcer. The nurse is caring for a client who is recovering from a gastric resection. The nurse provides teaching about how to prevent dumping syndrome. Which of the following statements are correct? Select all that apply. a. Do not consume fluids with meals b. Avoid consuming sugar, salt and milk c. Lie down after each meal d. Eat two large meals each day e. Increase carbohydrate intake - CORRECT ANSWER a., b., c. rationale: Fluids cause the intestines to rapidly push food through, causing an episode of dumping. One measure to prevent dumping syndrome is to avoid sugar, salt, and milk. When these elements move too quickly into the small intestine, dumping occurs.Dumping syndrome can occur after gastric resections when the contents of the stomach are rapidly moved into the small intestine. Symptoms of dumping syndrome include nausea, vomiting, cramping, sweating, and diarrhea. Measures to prevent dumping syndrome include consuming a low carb, high fat, high protein diet, avoiding fluid consumption with meals, avoiding sugar, salt and milk, and lying down after each meal. The patient may also take antispasmodic drugs to delay gastric emptying, if prescribed. The client has a chronic peptic ulcer and wants to know the difference between an acute and chronic peptic ulcer. How does the nurse educate the client? a. An acute ulcer is a superficial erosion, while a chronic ulcer extends through the muscular wall of the stomach b. An acute ulcer is treated with H2 blockers while a chronic ulcer is treated with proton pump inhibitors c. H. pylori is present with a chronic ulcer but not with an acute ulcer d. An acute ulcer lasts only a month and a chronic ulcer lasts greater than one month - CORRECT ANSWER a. rationale: When the erosion in the lining of the GI tract extends through the mucosal wall and muscle in a portion of the GI tract accessible to gastric secretions, it is called a chronic ulcer. Locations include the stomach, pylorus, duodenum and esophagus. An acute ulcer is in the same locations, but is a superficial erosion through the mucosal wall only. A nurse is caring for a client who is suffering from a gastric ulcer. Which of the following is an appropriate nursing intervention? Select all that apply. a. Take a histamine blocker b. Drink caffeinated beverages c. Take a proton pump inhibitor d. Drink plenty of milk e. Eat small, frequent meals - CORRECT ANSWER a., c., e. rationale: Histamine blockers or proton pump inhibitors should be given to reduce stomach acid.Small, frequent meals are less likely to cause irritation to an ulcer than large meals. The nurse is teaching a client who has been diagnosed with peptic ulcer disease about what foods to eat. Which of the following is a food that the client is allowed to eat with this diagnosis? Select all that apply. a. Citrus b. Purine containing foods c. Coffee d. Chocolate e. Tea - CORRECT ANSWER a., b. rationale: Citrus fruits are not contraindicated for a client with peptic ulcer disease.Purines are avoided for gout, but not peptic ulcer disease. The nurse is working with a client who has peptic ulcer disease. Which of the following labs is important to monitor with this condition? a. H/H (Hgb/hematocrit) b. Potassium c. Procalcitonin d. Lactic acid - CORRECT ANSWER a. rationale: In PUD, bleeding is a concern, so monitoring the H/H will alert the clinician of developing or worsening bleeding. The client with a duodenal ulcer asks the RN why an abx is part of the tx regimen. Which info should the nurse include in the response? a. abx decrease the likelihood of a 2ndary infection b. many duodenal ulcers are caused by H. pylori c. Abx are used in an attempt to sterilize the stomach d. May people have C. difficile, which can lead to ulcer formation - CORRECT ANSWER b. rationale: H. pylori infection is a major cause of peptic ulcers so tx includes abx therapy to eradicate the microorganism. Abx do not reduce the likelihood of a secondary infection, they treat the primary infection. Abx are not used to sterilize the bowel, and would upset the normal flor of the GI tract. C. diff is a contagious microorganism that can lead to severe diarrhea. A client with a peptic ulcer has been brought in to the healthcare clinic and is being assessed by the nurse for an upper GI bleed. Which of the following signs or symptoms would the nurse expect to see with this condition? Select all that apply. a. Melena b. Swelling in the lower legs c. Epigastric pain d. Hematemesis e. Abdominal fullness - CORRECT ANSWER a., c., d. rationale: "Epigastric pain", "Melena" and "Hematemesis" are correct. An upper GI bleed occurs in the upper portion of the gastrointestinal tract, including the area within the esophagus. Signs or symptoms associated with bleeding from this area include epigastric pain, vomiting blood, and dark blood in your stool, called melena. The nurse is caring for a client with peptic ulcer disease due to H. pylori. Which drug combinations should be given along with a macrolide antibiotic? a. Penicillin and Axid b. Amoxicillin and Prilosec c. Flagyl and Amphogel d. Tetracycline and sodium bicarbonate - CORRECT ANSWER b. rationale: H. pylori can be complicated to treat, because the bacteria quickly becomes resistant to antibiotics. Therefore, "triple therapy" is used. (When triple therapy fails, "quadruple therapy" is recommended.) Triple therapy consists of a macrolide antibiotic, a proton pump inhibitor, and a penicillin-related antibiotic. After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice - CORRECT ANSWER d. rationale: Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. The nurse is reviewing orders for a client with peptic ulcer disease (PUD). Which of the following would the nurse question? a. 500 mg calcium carbonate PO QID b. 40 mg pantoprazole PO daily c. 325 mg aspirin PO daily d. 20 mg famotidine PO BID - CORRECT ANSWER c. rationale: Aspirin and NSAIDS are avoided with PUD because they exacerbate symptoms. A client with Crohn's disease has been using whey protein shakes for weight gain. What information should the nurse give to this client about the safety of using these types of shakes? Select all that apply. a. Whey protein has been known to lower blood pressure in some people b. Whey protein may cause changes in cholesterol levels c. Whey protein is usually safe for use in adults when used at recommended amounts d. Whey protein has been shown to increase the risk of blood clots e. Whey protein powder can significantly increase blood glucose levels - CORRECT ANSWER a., b., c. rationale: Whey protein is a type of supplement that may be used to assist with weight gain because of the protein provided. Whey protein shakes can be helpful but they should be used with caution in some clients, particularly those who are lactose intolerant. Whey protein has also been shown to lower blood pressure, moderate blood glucose levels, reduce C-reactive protein levels (inflammatory markers), and can lower cholesterol levels.Whey protein has been shown to lower cholesterol levels in some clients.Whey protein is safe for most adults, unless the client is known to have a lactose intolerance. The nurse is giving a client an IV infusion of infliximab for Crohn's disease and notices the client has developed fever and chills during the infusion. What is a priority nursing intervention? a. Give diphenhydramine for the allergic reaction b. Report the findings to the provider c. Slow the infusion rate d. Give acetaminophen for the fever - CORRECT ANSWER c. rationale: The client is having an acute reaction to the infusion. The priority nursing action is to slow the infusion. Then the nurse should give the client acetaminophen for fever and notify the provider. The fever is not an allergic reaction, so diphenhydramine will not improve symptoms. A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the clients psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements. - CORRECT ANSWER b. rationale: Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the clients psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope. A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac) - CORRECT ANSWER c. rationale: Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid. A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? a. Client who underwent diverticula removal with a pulse of 106/min b. Client who had esophageal dilation and is attempting first postprocedure oral intake c. Client who had an esophagectomy with a respiratory rate of 32/min d. Client who underwent hernia repair, reporting incisional pain of 7/10 - CORRECT ANSWER c. rationale: The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for. The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections - CORRECT ANSWER a. , b. , c. , d. rationale: Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is. A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce - CORRECT ANSWER a., c., d., e. rationale: Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided. The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs. - CORRECT ANSWER b. rationale: This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery. A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy - CORRECT ANSWER d. rationale: Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the clients willingness and ability to follow the regimen. The other assessment findings are not as critical. A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs. - CORRECT ANSWER c. rationale: All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids. A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli - CORRECT ANSWER a., d. rationale: Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided. A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night - CORRECT ANSWER c. rationale: The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease. A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease. A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus - caused by paralysis of the colon - CORRECT ANSWER a. , b., d. rationale: Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon. A client has total gastrectomy. The nurse explains the need for longterm injections of which vitamin? a. Thiamine b. Folic acid c. Cyanocobalamin d. Niacin - CORRECT ANSWER c. rationale: the loss of parietal cells that secrete intrinsic factor results in Vitamin B12(cyanocobalamin) deficiency post-gastrectomy because intrinsic factor is needed for the absorption of Vitamin B21. The pt who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect r/t bowel function and care after surgery, which response should the nurse make? a. "You will be able to have some control over your bowel movement.s" b. "the stoma will require that you wear a collection device all the time." c. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch." d. The drainage will gradually become semisolid and formed. - CORRECT ANSWER b. rationale: a client wiht an ileostomy must always wear a collection device. The client has no contorl over bowel movements. Bowel irrigation is not performed to eliminate the need to wear a drainage pouch. The nurse is conduction a dietary teaching with a client who has dumping syndrome. The nurse encourages the client to avoid which foods that the client usually enjoys? select all that apply. a. eggs b. cheese c. fruit d. pork e. cookies - CORRECT ANSWER c. , e. rationale: Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following gastrectomy. Fruits and cookies containing simple carbohydrates will attract fluid into the GI tract, leading to symptoms of dumping syndrome. Eggs are higher in protein and fat (cholesterol), which will slow GI transit time, avoiding dumping syndrome. Cheese has variable amounts of protein and fat, and these are less likely to trigger dumping syndrome. Pork is high in protein, which slows GI transit time to reduce episodes of dumping syndrome. The client returning from a colonoscopy has been given a dx of Crohn's disease. The oncoming shift nurse expects to note which manifestations in the client? Select all that apply. a. Steatorrhea b. Firm, rigid abdomen c. Constipation d. Enlarged hemorrhoids e. diarrhea - CORRECT ANSWER a., e. rationale: Steatorrhea is often present in the client with Crohn's disease. Diarrhea is also a key feature, but unlike ulcerative colitis, the loose stoll usually does not contain blood and is usually less frequent in number of episodes. A firm rigid abdomen is not a manifestation of Crohn's disease. Constipation is not a manifestation of Crohn's disease. Hemorrhoids are nota manifestation of Crohn's disease. The client with diverticular disease is scheduled for a sigmoidoscopy and suddenly reports severe abdominal pain. On examination the nurse notes a rigid abdomen with guarding. Which action should the nurse take next? a. Notify the healthcare provider b. Place the client in a more comfortable position c. Keep the client distracted untill the procedure begins d. Tell the client that the test will show what is causing his problem - CORRECT ANSWER a. rationale: perforation of an obstructed diverticulum can cause abcess formation or generalized peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain. Because treatment of this complication is beyond the scope of independent nursing practice, the healthcare provider must be notified. Placing the client in a position of comfort could be attempted after notifying the HCP of the complication. The nurse is caring for a client diagnosed with Crohn's disease. Which statement indicates more teaching is needed? a. "I am at risk for anemia and electrolyte disturbances" b. "I will deal with chronic constipation" c. "A high-calorie, high-protein diet is best" d. "I will have periods of remission and periods of exacerbation" - CORRECT ANSWER b. rationale: A client with Crohn's disease will have frequent episodes of diarrhea, not constipation. The nurse is educating the client with GERD about ways to minimize symptoms. Which info in the client's history should the RN address as indicators that need to be changed? Select all that apply. a. Lifting weights for exercise b. being vegetarian c. having a body mass index of 26 d. taking calcium carbonate tablets e. drinking 2-4 cups of coffee daily - CORRECT ANSWER a. , c., e. rationale: lifestyle modifications can minimize symptoms of GERD. Anything that increases intra-abdominal pressure should be avoided, such as lifting weights. Obesity or being overweight (BMI of 26) also aggravates symptoms. Coffee, cola, other sources of caffeine, and chocolate decrease lower esophageal sphincter tone and can increase symptoms of GERD. Being a vegetarian does not increase risk of GERD. Calcium carbonate tablets often aid in symptom relief. A nurse is providing discharge teaching to a client who has had a colostomy surgically placed during the hospital stay. What information would the nurse most likely include about the stoma for this clent? Select all that apply. a. The stoma is typically round or oval in shape b. The stoma is usually red in color c. The stoma is painful when touched d. The stoma is usually flat or inverted e. The stoma may be slightly swollen just after surgery - CORRECT ANSWER a. , b., e. rationale A client with a new colostomy may be surprised at the appearance of the stoma and requires teaching about what to expect as well as how the stoma may change. The stoma site may be slightly swollen just after surgery, but this should resolve with time. The client should understand what a normal stoma looks like in order to detect potential complications if there is a change in appearance. A red or pink stoma indicates high vascularization, which is normal. If the stoma becomes pale pink, the client may have low hemoglobin and hematocrit levels. A client with diverticulosis had a colostomy placed 5 days ago and is now being discharged. Which of the following would NOT be appropriate discharge teaching for this patient? a. Increase fluid intake b. Increase fiber intake to 25-30 g/day c. Masticate fully before swallowing d. Let any sealers dry before applying a new appliance - CORRECT ANSWER b. rationale: Fiber intake should be introduced slowly after a colostomy, and only after the first 2 months. Therefore, increasing the fiber intake to 25-30 g/day right away would be inappropriate. A client with diverticulosis had a colostomy placed yesterday. Which of the following assessment findings would be the MOST concerning to the nurse? a. Red stoma b. Pale-pink stoma c. Red skin around stoma d. Purple stoma - CORRECT ANSWER d. rationale: This is the most concerning finding as it indicates severe ischemia and possibly even strangulation of the stoma. This needs to be addressed immediately. A nurse is working in a busy clinic and must provide teaching to a client about caring for a new colostomy. The nurse has a nurse aide to help with some tasks. Which of the following tasks could the nurse delegate to the unlicensed assistive personnel while working with this client? a. Checking and measuring the output from the foley b. Instructing the client about which foods are least likely to cause odor c. Gathering informational materials to give to the client d. Teaching the client about how to change the colostomy bag - CORRECT ANSWER a. rationale: "Checking and measuring the output from the foley" is correct. In a specialized care setting, unlicensed assistive personnel can provide client care in the form of basic tasks that are not outside of their scope of practice. In this situation, the nurse may only delegate the measurement of urine output from the foley. All other practices of providing education and teaching should be done by the nurse. A nurse is changing the colostomy bag for a patient with a new colostomy. Which elements of skin care should the nurse provide during this process? Select all that apply. a. Avoiding adhesive remover or water when removing the pouch from the skin b. Drying the skin thoroughly before reapplying the pouch c. Avoiding ripping the pouch off of the patient's skin d. Cleaning around the stoma with warm water and a washcloth e. Using sterile gauze to wipe the stoma and absorb exudate - CORRECT ANSWER b., c., d. rationale: -"Avoiding ripping the pouch off of the patient's skin", "Cleaning around the stoma with warm water and a washcloth" and "Drying the skin thoroughly before reapplying the pouch" are correct. A patient who uses a colostomy bag is at risk of skin breakdown around the ostomy site. The pouch should be removed by pushing gently down on the skin with one hand, while pulling up on the pouch with the other hand. Skin care includes inspecting the skin and stoma site carefully, washing the skin with soap and water and ensuring the skin is dry before applying a new pouch. If the skin is irritated, it is possible that the pouch opening is too large, excessively exposing the surrounding skin to feces which leads to skin irritation and breakdown. A nurse is helping a client with colostomy irrigation. Which best describes effluent, which is part of this process? a. The type of skin barrier that is used to cover the stoma b. The stool that comes out of the colostomy c. The fluid that is instilled into the stoma d. The name of the applicator used to instill the fluid - CORRECT ANSWER b. rationale: Colostomy irrigation involves instilling fluid into a client's stoma using a specialized piece of equipment. The stool and liquid that comes out of the stoma after the irrigation is called the effluent. The effluent should be collected in a container or passed into the toilet during the irrigation. A nurse is working with a client who had bowel surgery with placement of a colostomy one month ago. The client has not had any complications following colostomy surgery so far. Which nutritional recommendation should the nurse give that is appropriate for a client in this stage of recovery? a. Limit the amount of fluids consumed b. Thoroughly chew food c. Measure waist circumference once per week d. Try new foods frequently to further improve output - CORRECT ANSWER b. rationale: "Thoroughly chew food" is correct. A client who has had a colostomy placed and who is not having complications can eat a normal diet and enjoy food as before the surgery. Although this client is still in a relatively early stage of recovery, the nurse should reinforce with the client to chew food thoroughly while eating and drink plenty of fluids, because blockages and dehydration are a common problem related to colostomies. An ostomy nurse is caring for a client who is scheduled for surgery for placement of a colostomy. The nurse explains that it is important to choose the most appropriate site for the stoma. Which of the following regarding stoma location is accurate for the nurse to include in teaching? a. Without proper placement, the stoma will be sunken below the skin level b. The stoma is more likely to become infected if it is not exactly placed in the proper location c. Placement of the stoma in the right location will affect how you feel about having it d. If the stoma is not in the right place, you may have trouble reaching it to take care of it - CORRECT ANSWER d. rationale: One of the most important aspects to consider for the client who will have a stoma is to determine the correct location of the site. A stoma that is poorly positioned may be difficult for the client to reach, which means the client may have a harder time taking care of it. This could lead to a greater risk of skin complications and infection. The client has an acute flare up of diverticulitis. Nursing interventions to prevent complications include which of the following? Select all that apply. a. Give antibiotics by IV b. Give the client an enema c. Maintain NPO status d. Give antispasmodics e. Provide IV fluids - CORRECT ANSWER a., c., e. rationale: IV antibiotics are necessary to reduce infection during a flare-up.During an acute flare up of diverticulitis, the client should have IV fluids and be placed on bowel rest with IV antibiotics.IV fluids are necessary when the client is NPO to avoid dehydration. The dietary plan for a client with diverticulitis includes which of the following? a. Low carb, high fiber b. High protein, restrict fluids c. Low protein, high fat d. High fiber, increased fluids - CORRECT ANSWER d. rationale: Clients with diverticulitis have pouches of fecal matter stuck in their diverticula. High fiber, increased fluids, and low fat consumption promote movement in the GI tract. A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? - CORRECT ANSWER Widened pulse pressure A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER An aura is a sensory warning that a seizure is imminent A nurse is reinforcing teaching with a client who has a new diagnosis of primary open angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Driving can be dangerous due to the loss of peripheral vision. Laser surgery can help reestablish the flow of aqueous humor. A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? - CORRECT ANSWER Protect the client's head A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? - CORRECT ANSWER Weakness of the lower extremities A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? - CORRECT ANSWER A TIA can precede an ischemic stroke A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery? - CORRECT ANSWER Intraocular hemorrhage A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? - CORRECT ANSWER Swelling behind the affected ear. A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement? - CORRECT ANSWER Dysphagia A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Instill a diluted alcohol solution into the ear after swimming. A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? - CORRECT ANSWER Cheyne-Strokes A nurse reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? - CORRECT ANSWER The client has a pacemaker A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Darken the lights A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? - CORRECT ANSWER Oral nasal suction equipment A nurse if reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? - CORRECT ANSWER Weakness of the distal extremities A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurologic status? - CORRECT ANSWER Level of consciousness A nurse is collecting data from a client who has a high thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? - CORRECT ANSWER Report of a headache A nurse is caring for a client who has a closed head injury. The nurse should place the client in which of the following positions? - CORRECT ANSWER Semi-Fowler's A nurse is reinforcing discharge teaching with a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER You should expect to see flashing lights in front of the affected eye after the procedure A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? - CORRECT ANSWER The client rigidly extends his arms A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority? - CORRECT ANSWER Dysphagia A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect? - CORRECT ANSWER The client's urine output is 250 mL/hr A nurse is collecting data from a client who has a new diagnosis of acute angle closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? - CORRECT ANSWER Severe eye pain A nurse is reinforcing teaching with a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER Avoid sudden movements A nurse in a rehabilitation center is collecting data from a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect? - CORRECT ANSWER Difficulty with speech A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching? - CORRECT ANSWER I will avoid bending over A nurse is collecting data from a client who has a recent head trauma and a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI? - CORRECT ANSWER Specific gravity A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? - CORRECT ANSWER Feeling of fullness in the ear A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. The nurse should recognize which of the following findings is consistent with this diagnosis? - CORRECT ANSWER Elevated protein A nurse is reinforcing teaching with the family of a client who has stage 2 Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching? - CORRECT ANSWER Limit choices offered to the client A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy. Which finding should cause the nurse to clarify routine preparation orders with the physician? a. The patients age b. Presence of severe diarrhea c. Complaints of abdominal cramping d. Patients weight is 10% below ideal body weight - CORRECT ANSWER b. Presence of severe diarrhea -Routine preparation with severe diarrhea can result in electrolyte imbalance. Bowel preparation may not be ordered for patients with bleeding or severe diarrhea. A. C. D. The patients age, complaints of abdominal cramping, or current weight are not contraindications for the routine preparation for this diagnostic test. The nurse is caring for a patient who is placed on a modified bland diet. Which should be removed before serving the patients dinner tray? a. Salt b. Sugar c. Pepper d. Mayonnaise - CORRECT ANSWER c. Pepper -Pepper, which is spicy, would not be included in a bland diet. A. B. D. These food items are bland. The nurse is preparing to initiate a tube feeding through a patients nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube? a. Sterile water b. Normal saline c. Cranberry juice d. Carbonated water - CORRECT ANSWER b. Normal saline -Normal saline is used for NG tube irrigation to prevent loss of electrolytes. A. Sterile water could cause an electrolyte imbalance in the patient. C. D. Cranberry juice and carbonated water are not appropriate fluids to flush a nasogastric tube. The nurse is inspecting a patients oral cavity. What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient? a. Loose teeth are unsightly to the patient. b. Loose teeth can cause dental abscesses. c. Loose teeth can be aspirated into the airway. d. Loose teeth can prevent the patient from eating. - CORRECT ANSWER c. Loose teeth can be aspirated into the airway. -Loose teeth can be aspirated into the airway and become a choking risk. A. The nurse is not inspecting for loose teeth because it is unsightly to the patient. B. The nurse is not inspecting for loose teeth because of the risk for dental abscesses. D. Missing teeth is more likely to prevent a patient from eating. The nurse is collecting data from a patient who is scheduled for an ileostomy. Which technique should the nurse use to help identify optimal stoma placement? a. Palpation b. Inspection c. Percussion d. Auscultation - CORRECT ANSWER b. Inspection -Inspection is observation. The abdomen is visually inspected to note the condition of the skin, the contour, belt line, and other factors that would affect optimal stoma placement. A. C. D. These techniques of data collection would not be appropriate when determining optimal placement for a stoma. A licensed practical nurse (LPN) who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN). Which action should the nurse take? a. Provide patient care as assigned. b. Ask another nurse to trade patients for the shift. c. Notify the supervisor that another nurse will need to be pulled. d. Notify the charge nurse that an adjustment in the patient assignment is necessary. - CORRECT ANSWER d. Notify the charge nurse that an adjustment in the patient assignment is necessary. -Usually, registered nurses (RNs) are responsible for administering PN. Therefore, the LPN should discuss the assignment with the charge nurse and seek a possible adjustment. A. Providing patient care as assigned would be beyond the LPNs scope of practice. B. The LPN cannot make a patient care assignment change. C. The LPN needs to work through the charge nurse. The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used? a. Palpation b. Inspection c. Percussion d. Auscultation - CORRECT ANSWER a. Palpation -Light palpation uses touch and depresses the abdomen 0.5 to 1 inch. B. Inspection is looking at or observing an area. C. Percussion is using the hands and fingers to produce a sound that identifies the density of the organs beneath the area being percussed. D. Auscultation is the use of a stethoscope to listen for sounds. The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take? a. Advance the NG tube 2 inches. b. Change the suction setting to high. c. Reinsert the NG tube in the other nare. d. Irrigate the NG tube with 30 milliliters of normal saline. - CORRECT ANSWER d. Irrigate the NG tube with 30 milliliters of normal saline. -The nurse should irrigate the NG tube with 30 mL of normal saline to see if it is obstructed or on the stomach wall. B. Suction should remain on a low setting to prevent damage to the lining of the stomach. A. The tube should not be advanced without an HCPs order. C. The NG tube should not be pulled and reinserted without an HCPs order. A patient receiving 70 mL of tube feeding per hour has a residual amount of 120 mL. What action should the nurse take? a. Slow the feeding to 35 mL/hr. b. Continue the feeding as ordered. c. Increase the feeding to 100 mL/hr. d. Hold the feeding, and notify the physician. - CORRECT ANSWER d. Hold the feeding, and notify the physician. -If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. A. Slowing the feeding is not going to reduce the amount of residual. B. Continuing the feeding as ordered increases the patients risk for aspiration or vomiting. C. Increasing the feeding will increase the patients risk for aspiration or vomiting. The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding? a. Absent bowel sounds b. Normal bowel sounds c. Hypoactive bowel sounds d. Hyperactive bowel sounds - CORRECT ANSWER c. Hypoactive bowel sounds -Hypoactive bowel sounds are bowel sounds that are infrequent (normal is 5 to 30) over a 5- minute period and can occur in patients with a paralytic ileus or following abdominal surgery. A. Since the nurse heard sounds, absent bowel sounds would be incorrect to document. B. Normal bowel sounds occur 5 to 30 times over a 5 minute period. D. Hyperactive bowel sounds would be more than 30 sounds over a 5 minute period. A patient receiving a tube feeding at 60 mL/hr has a residual of 10 mL. What action should the nurse take? a. Continue the feeding as ordered. b. Slow the feeding to 35 mL/hour. c. Decrease the feeding to 10 mL/hour. d. Hold the feeding, and notify the physician. - CORRECT ANSWER a. Continue the feeding as ordered. -If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. This feeding can be continued as ordered, as the residual amount is only 10 mL. B. C. D. The feeding does not need to be slowed, decreased, or held. While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level. How should the nurse interpret this test result? a. The patient is cured. b. The patient has a residual or recurrent tumor. c. The liver has been damaged by chemotherapy. d. The patient should be placed in protective isolation - CORRECT ANSWER b. The patient has a residual or recurrent tumor. -CEA and carbohydrate antigen 19-9 are markers used to monitor gastrointestinal (GI) cancer treatment effectiveness and detect recurrence. A. An elevated level does not indicate that the patient is cured. C. An elevated CEA level would not be seen in the absence of disease and does not indicate liver function. D. Extremely low white blood cell counts would be used to determine if the patient needed to be placed in protective isolation. The nurse is reinforcing teaching for a patient who is scheduled for an upper GI series. Which patient statement indicates teaching has been effective? a. It is an estimated rectal cholangiopancreatophonography. b. It is a scope inserted into the duodenum with dye injection. c. It is a sigmoidoscopy with radiography after injection of dye. d. It is an x-ray of the esophagus, stomach, and duodenum using barium. - CORRECT ANSWER d. It is an x-ray of the esophagus, stomach, and duodenum using barium. -An upper GI is an x-ray of the esophagus, stomach, and duodenum using barium. A. B. C. These statements do not correctly explain an upper GI series. A patient is being prepared for an upper GI series. Which statement indicates that the patient understands the preparation for this test? a. I should eat a soft diet the night before the procedure. b. I must not eat or drink for 4 hours after the procedure. c. Ill be given a clear liquid diet the night after the procedure. d. I cant have anything to eat or drink for 6 to 8 hours before the procedure. - CORRECT ANSWER d. I cant have anything to eat or drink for 6 to 8 hours before the procedure. -An appropriate patient diet preparation for an upper GI series is placing the patient on NPO restriction 6 to 8 hours before the procedure for best visualization. A. B. C. These statements indicate that the patient does not understand the correct way to prepare for this diagnostic test. The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which action should the nurse take? a. Lay the patient supine. b. Elevate the head of the bed 10 degrees. c. Place the patient in high Fowlers position. d. Place the patient onto the left side with knees flexed. - CORRECT ANSWER c. Place the patient in high Fowlers position. -When feedings are administered, patients must be positioned in a sitting or high Fowlers position to reduce the risk of aspiration. A. B. D. These positions increase the patients risk of aspiration. The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose. What action should the nurse take before starting the feeding? a. Listen to bowel sounds. b. Check the pH of gastric aspirate. c. Secure the NG tube with additional tape. d. Irrigate the tube with 10 mL of sterile water. - CORRECT ANSWER b. Check the pH of gastric aspirate. -Prior to instilling anything into the NG tube, it is essential to verify placement of the NG tube; after x-ray is performed, the preferred method of verification is to check the pH of the gastric aspirate. A. Bowel sounds can be auscultated at any time. C. The NG tube should have been secured after insertion. D. The tube is irrigated with normal saline and not sterile water. The nurse is caring for a patient with cultural dietary needs. Which question should the nurse include in a cultural dietary assessment? a. What restaurants do you go to? b. Which foods do you most commonly eat? c. Which unavailable cultural foods do you prefer to eat? d. What foods are available in the country where you lived? - CORRECT ANSWER b. Which foods do you most commonly eat? -Understanding cultural influences, respecting them, and assisting the patient to maintain desired cultural practices are important for nutritional maintenance. Finding out which foods the patient likes will allow for planning to include those foods in meals. A. C. D. These questions do not necessarily assess the patients cultural dietary preferences. A patient receiving tube feedings at 50 mL/hour has a residual volume of 250 mL of undigested tube feeding. What action should the nurse take? a. Discard aspirated tube feeding, and run tube feeding as ordered by the physician. b. Report amount of aspirated tube feeding to the RN for consultation with the physician. c. Return aspirated tube feeding to the patient, and run feeding at a slower rate of 20 mL/hour. d. Return aspirated tube feeding to the patient, and wait 2 hours before restarting tube feeding at 50 mL/hr. - CORRECT ANSWER b. Report amount of aspirated tube feeding to the RN for consultation with the physician. -As the residual amount is more than 100 mL or the amount specified by the agency or physician, the RN and the physician are notified, and the feeding will likely be stopped to prevent vomiting or aspiration. A. C. D. The nurse should not continue this tube feeding because of the risk of vomiting or aspiration. The nurse is reviewing GI function with a patient. Which body structure should the nurse emphasize as accomplishing mechanical digestion in the stomach? a. Mucosa b. Gastric glands c. Smooth muscle layers d. Striated muscle layers - CORRECT ANSWER c. Smooth muscle layers -The stomach wall has three layers of smooth muscle that provide very efficient mechanical digestion to change food to a thick liquid called chyme. A. B. D. These structures do not perform mechanical digestion in the stomach. The nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding about the function of hydrochloric acid in gastric juice? a. Digestion of starch b. Inactivation of pepsin c. Destruction of pathogens d. Maintenance of a pH of 7 to 8 - CORRECT ANSWER ANS: C Hydrochloric acid creates the pH of 1 to 2 that is necessary for pepsin to function and to kill most microorganisms that enter the stomach. A. B. D. These responses do not explain the function of hydrochloric acid in gastric juice. The nurse is caring for a patient who has a non-vented nasogastric tube. Which suction setting should the nurse select? a. Low continuous suction b. High continuous suction c. Low intermittent suction d. High intermittent suction - CORRECT ANSWER ANS: C If suction is ordered, low intermittent suction is used with non-vented nasogastric tubes (Levin). A. B. D. These settings are inappropriate for this type of nasogastric tube. The nurse is assisting with the care of a patient who has PN infusing. Which data should be the most concerning to the nurse? a. Heart rate 92 beats/min b. Respiratory rate 16/min c. Blood glucose 260 mg/dL d. Urine output 60 mL in the past hour - CORRECT ANSWER ANS: C The glucose level is elevated. It is important to monitor glucose levels as ordered and to look for signs of hyperglycemia due to the high dextrose in PN. A. B. D. This data is all within normal limits. The nurse is assisting with the care of a patient who has PN containing dextrose 50% infusing. The patient asks why the rate keeps being increased. How should the nurse respond to this patient? a. It is important to increase the PN whenever your blood sugar is low. b. It is important to do this to help reduce bile secretion and prevent heartburn. c. By changing the rate, it helps your body increase absorption of the electrolytes. d. It is started slowly and increased slowly to allow your pancreas to adjust insulin levels. - CORRECT ANSWER ANS: D PN is started slowly to give the pancreas time to adjust to increasing insulin production for the high amounts of glucose in the PN. A. The rate is not changed because the patients blood sugar is low. B. The rate is not changed because of bile secretion or heartburn. C. The rate is not changed to encourage the body to absorb electrolytes. The nurse is caring for a patient who has a permanent gastric feeding tube. What nursing action would be most helpful to prevent aspiration during feedings? a. Administer careful oral care daily. b. Check placement of the tube hourly. c. Elevate head of bed at least 30 degrees. d. Ask the physician to order daily x-rays. - CORRECT ANSWER ANS: C To prevent aspiration during tube feedings the nurse should elevate the head of the patients bed more than or equal to 30 degrees at all times for feeding. A. B. D. These actions would not prevent the patient from developing aspiration with tube feedings. A patients Levin NG tube inserted for decompression of the bowel, which is connected to low intermittent suction, is not draining. The patient reports feeling full, uncomfortable, and nauseous. After verifying tube placement, what action should the nurse take next? a. Provide an antiemetic. b. Remove the nasogastric tube. c. Notify the physician immediately. d. Gently irrigate tube with normal saline. - CORRECT ANSWER ANS: D Gently irrigate the tube with normal saline to ensure patency and that the tube does not adhere to the stomach wall. A. An antiemetic would not help the tube drain. B. The NG tube cannot be removed without a health care providers (HCPs) order. C. The physician may need to be notified but after an attempt at irrigation is made. The nurse is reinforcing teaching for a patient who is scheduled for an esophagogastroduodenoscopy. Which patient statement indicates understanding of preprocedure diet instructions? a. I may have a full liquid breakfast. b. I will not eat or drink 12 hours before the procedure. c. I can drink only clear liquids 2 hours before the procedure. d. I will have nothing to eat or drink 8 to 12 hours before the procedure. - CORRECT ANSWER ANS: D The patient will have nothing to eat or drink 8 to 12 hours typically before the procedure. A. B. C. These statements indicate the patient does not understand the pre-procedure diet instructions. The nurse is preparing a patient for an NG tube insertion. To decrease the patients anxiety about insertion of a nasogastric tube, what should the nurse do? a. Administer a narcotic. b. Administer a sedative. c. Explain the procedure. d. Assess the patients gag reflex. - CORRECT ANSWER ANS: C Explaining what is to be done reduces patient anxiety because the patient knows what to expect and can prepare to cope with it. A. B. A narcotic or sedative is not helpful when inserting an NG tube into a patient. D. The patients gag reflex will be assessed during tube insertion. The nurse is caring for a patient on a clear liquid diet. The nurse should recognize that the patient requires further teaching if the patient requests which food? a. Gelatin b. Beef broth c. Cranberry juice d. Coffee with cream - CORRECT ANSWER ANS: D Cream is not on a clear liquid diet. A. B. C. Clear liquids are liquid items that you can see through. The nurse is caring for a patient on a full liquid diet. The nurse recognizes that the patient understands teaching if the patient requests which food item? a. Salad b. Cheese c. Milkshake d. Hamburger - CORRECT ANSWER ANS: C A full liquid diet is any item that is liquid at room temperature as a milkshake would be. A. B. D. These food items are appropriate for a regular diet. A patient recovering from GI surgery 4 hours ago is alert and oriented and complains of feeling thirsty. Diet orders read, clear liquids, advance as tolerated. Which action should the nurse take? a. Notify the RN. b. Ask the patient if she has passed any flatus. c. Allow the patient to take small sips of water. d. Inform the patient she must remain NPO (nothing by mouth) until she has bowel sounds. - CORRECT ANSWER ANS: C Because there is an order for liquids and the patient is stable, the nurse can provide the patient with sips of fluid. A. RN does not need to be informed prior to giving the fluids. B. D. There does not appear to be an advantage to maintaining patients NPO postoperatively until bowel function returns. If ordered, nutrition can be provided to patients undergoing GI surgery early postoperatively which may improve their recovery with fewer complications. A patient is prescribed PN. For which percentage of dextrose should the nurse prepare the patient to have a central venous catheter placed for this infusion? a. 5% b. 8% c. 10% d. 12% - CORRECT ANSWER ANS: D PN dextrose greater than 12% should be administered through a central venous catheter into a large vein to prevent vein irritation and thrombophlebitis. A. B. C. These dextrose percentages can be safely administered through a peripheral site. The nurse is palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant. How deep should the nurse depress this patients abdomen? a. 1 inch b. 2 inches c. 3 inches d. 4 inches - CORRECT ANSWER ANS: A When palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant, the LPN should depress the abdomen no more than 1 inch. B. C. D. Deep palpation of the abdomen is done only by physicians and highly skilled nurses. While assessing a patients abdomen, the nurse notes a yellow-tinge to the skin. How should the nurse document this finding? a. Striae b. Jaundice c. Caput medusae d. Spider angioma - CORRECT ANSWER ANS: B Yellowing of the skin is termed jaundice. A. Striae are light silver-colored or thin red lines on the skin. C. Caput medusae are bluish purple swollen vein patterns extending out from the navel. D. Spider angiomas are thin reddish purple vein lines close to the skin surface. The nurse is reinforcing teaching for a patient who is on a clear liquid diet. Which patient statement(s) indicates correct understanding of the foods that would be appropriate on this diet? (Select all that apply.) a. Beef broth b. Grape juice c. Apple juice d. Orange gelatin e. Tea with sugar f. Vanilla ice cream - CORRECT ANSWER ANS: A, C, D, E Clear liquids are liquid items that you can see through. B. F. Ice cream and grape juice are not on a clear liquid diet. The nurse is contributing to the teaching plan for another nurses team of patients. Which patients should the nurse expect to be scheduled for an upper GI series? (Select all that apply.) a. A 45-year-old with a suspected hiatal hernia b. A 19-year-old with symptoms of appendicitis c. A 52-year-old with a family history of polyps d. A 78-year-old who has frank blood in his stool e. A 65-year-old who is receiving treatment for hemorrhoids f. A 33-year-old who is experiencing symptoms of pyloric stricture - CORRECT ANSWER ANS: A, C, F Upper GIs are used to detect such things as strictures, ulcers, tumors, polyps, hiatal hernias, and motility problems in the upper GI tract. E. Hemorrhoids are not detected or treated with an upper GI series. B. Appendicitis is not detected with an upper GI series. D. Frank blood in the stool is indicative of a lower GI problem. The nurse is contributing to a patients plan of care. Which patients should the nurse recommend as benefiting from PN? (Select all that apply.) a. A patient who has esophageal cancer b. A patient scheduled for toe amputation c. A patient who has just had an appendectomy d. A patient who has been admitted with chest pain e. A patient with severe burns across the face and chest f. A patient who has respiratory distress from emphysema - CORRECT ANSWER ANS: A, E Patients with conditions such as burns, trauma, cancer, AIDS, malnutrition, anorexia nervosa, or fever, or those undergoing major surgery may need PN. The patient with esophageal cancer or burns across the face and chest may have difficulty swallowing and need nutritional support via PN. B. C. D. F. These patients may not necessarily benefit from PN. The nurse is reinforcing teaching for a patient who has hepatitis. Which functions of the liver should the nurse include in the teaching? (Select all that apply.) a. Form bilirubin b. Produce white blood cells c. Synthesize clotting factors d. Store sodium and potassium e. Synthesize essential amino acids f. Phagocytize worn red blood cells - CORRECT ANSWER ANS: A, C, F The liver forms bilirubin, synthesizes clotting factors, and phagocytizes worn out red blood cells. B. D. E. These actions are performed by other body organs or functions. The nurse is reinforcing teaching provided to a patient who has a small bowel obstruction. Which processes occur in the small intestine that should be included in this teaching? (Select all that apply.) a. Production of bile b. Absorption of water c. Production of insulin d. Mechanical digestion of food to chyme e. Production of enzymes to complete carbohydrate metabolism f. Production of peptides to complete the digestion of proteins to amino acids - CORRECT ANSWER ANS: E, F Enzymes to complete carbohydrate metabolism and production of peptides to digest proteins occur in the small intestines. A. B. C. D. These processes occur in other body organs. The nurse is reviewing structures within the hepatobiliary system with a patient with liver disease. Which structures should the nurse identify as being a part of this system? (Select all that apply.) a. Liver b. Colon c. Jejunum d. Bile duct e. Esophagus f. Gallbladder - CORRECT ANSWER ANS: A, D, F The liver, bile duct, and gallbladder make up the hepatobiliary system. B. C. E. These organs are a part of the GI system. The nurse is participating in a local health fair. Which should the nurse include in a presentation on aging changes associated with the GI system? (Select all that apply.) a. Decreased peristalsis b. Increased constipation c. Decreased sense of taste d. Increased periodontal disease e. Decreased risk of colon cancer - CORRECT ANSWER ANS: A, B, C, D The sense of taste becomes less acute, and there is greater likelihood of periodontal disease and oral cancer. There may be difficulties with chewing if teeth have been lost. Secretions throughout the GI tract are reduced, and the effectiveness of peristalsis diminishes because of loss of muscle elasticity and slowed motility. Indigestion may become more common, especially if the lower esophageal sphincter (LES) loses its tone, and there is greater chance of peptic ulcer. In the colon, diverticula may form. Constipation may be a problem, as may hemorrhoids. E. The risk of colon cancer also increases with age. A patient is diagnosed with liver failure. Which vitamin supplements should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Vitamin C b. Vitamin D c. Vitamin K d. Vitamin B6 e. Vitamin B12 - CORRECT ANSWER ANS: B, C, E The liver stores the fat-soluble vitamins A, D, E, and K and the water-soluble vitamin B12. A. Vitamin C is a water-soluble vitamin that is not stored in the liver. D. The liver does not store Vitamin B6. A patient is upset to learn that an occult blood test of a stool specimen was positive for blood. What should the nurse assess in this patient to determine if the results were falsely positive? (Select all that apply.) a. Ingestion of fish b. Use of aspirin or NSAIDs c. Recent intake of whole milk and cheese d. Ingestion of red meat three days before the test e. Recent dental procedure causing bleeding gums - CORRECT ANSWER ANS: A, B, D, E False-positive occult blood results can occur with bleeding gums following a dental procedure; ingestion of red meat within 3 days before testing; ingestion of fish, and use of drugs, including aspirin and NSAIDs. C. Whole milk and cheese are not identified as causing a false positive occult blood test of a stool specimen. The nurse is caring for a patient recovering from an endoscopic retrograde cholangiopancreatography (ERCP). Which findings should the nurse report to the charge nurse immediately? (Select all that apply.) a. Nausea and vomiting b. Onset of a fever and chills c. Urine output 100 mL the last hour d. Heart rate of 110 beats per minute e. Increased right upper quadrant pain - CORRECT ANSWER ANS: A, B, D, E After an ERCP the nurse should report nausea and vomiting, onset of fever and chills, rapid heart rate, and increased right upper quadrant pain which could indicate an infection or perforation of the pancreas. C. Urine output of 100 mL the last hour would not need to be reported to the charge nurse. The nurse is caring for a patient of Mexican American descent who is experiencing diarrhea. Which foods should the nurse expect the patient to select for the next days meals? (Select all that apply.) a. Fish b. Beef c. Cheese d. Chicken e. Fresh Fruit - CORRECT ANSWER ANS: A, D, E Diarrhea is considered a hot disease and would be treated by eating cold foods such as fish, chicken, and fresh fruit. B. C. These food items are considered hot substances, used to treat cold health problems. anemia - CORRECT ANSWER a deficiency of RBCs, hemoglobin (Hgb), or both, in the circulating blood; weakness, shortness of breath due to decreased oxygen to the tissues refers to a symptom or condition secondary to another problem and is not a diagnosis Anemia Pathophysiology - CORRECT ANSWER a decreased in the number of RBCs can be traced to three conditions: 1. impaired production of RBCs; aplastic anemia, nutrition deficiencies 2. increased destruction of RBCs; hemolytic or sickle cell anemia 3. massive or chronic blood loss can be related to genetic problems in certain cultures Anemia Etiology - CORRECT ANSWER *dietary deficiencies: iron, folic acid, vitamin B12 *pernicious anemia: lack of intrinsic factor in stomach secretions; necessary for b12 absorption *hemolysis: destruction or lysis of RBCs; leads to hemolytic anemia; *thalassemia anemia: hereditary found in certain cultures *chronic disease Anemia signs and symptoms - CORRECT ANSWER paleness (pallor), tachycardia, tachypnea, fatigue, shortness of breath, numbness of hands or feet, weakness, sore beefy red tongue, fissures at corner of mouth, inflamed tongue (glossitis), spoon-shaped fingernails Anemia Diagnostic tests - CORRECT ANSWER CBC, Hgb, Hct, serum iron, ferritin, TIBC, serum folate, bone marrow biopsy Anemia Therapeutic Measures - CORRECT ANSWER treatment begins with elimination of causes; intake of deficient nutrient can be increased in diet or by taking a supplement; change cooking habits, decrease alcohol intake, control chronic diarrhea; acute symptoms may need blood transfusion Nursing process for anemia - CORRECT ANSWER monitor Hgb, Hct levels, lab values, report any downward trend, monitor response to therapy, fatigue level, ability to ambulate safely and perform ADLs; monitor dyspnea, oxygen saturation (if Hgb levels are low O2 sats may not be accurate); assess for pallor in skin and conjunctivae Aplastic Anemia pathophysiology - CORRECT ANSWER differs from other types of anemia in that the bone marrow becomes fatty and unable to produce enough RBCs; also called hypoplastic anemia; cells that are produced are normal, but there are not enough of them to sustain life; left untreated=fatal pancytopenia - CORRECT ANSWER reduced numbers of all cells from the bone marrow Aplastic Anemia etiology - CORRECT ANSWER may be congenital or due to exposure of toxic substances, chemotherapy meds, use of cardiopulmonary bypass during surgery, bacterial infection, viral infection, or autoimmune disease Aplastic Anemia signs and symptoms - CORRECT ANSWER vary with severity of bone marrow failure; progressive weakness, fatigue, pallor, shortness of breath, headaches, pancytopenia worsens, tachycardia, heart failure, ecchymoses, petechiae, blood oozing from mucous membranes, injection sites, bleeding into vital organs, infection occurs because of low WBCs Aplastic Anemia diagnostic tests - CORRECT ANSWER CBC; usually all values are very low; sometimes RBC are normal due to longer life span; bone marrow biopsy most definitive; TIBC, Serum iron Aplastic Anemia therapeutic measures - CORRECT ANSWER early identification of cause and correction of underlying problem; transfusions, steroids: to stimulate production of cells in weakened marrow; immunosuppressants if autoimmune is the cause; hormones may work to increase the viability of the marrow interventions to prevent bleeding - CORRECT ANSWER *electric razor *soft toothbrush *avoid invasive procedures: enemas, douches, suppositories, rectal temps *avoid IM injections *avoid injury when checking BP: pump cuff only until pulse is obliterated *maintain pressure on IV, blood draw, and other puncture sites for 5 minutes *encourage use of shoes/slippers when out of bed *keep area clutter-free to prevent bumps/bruises *avoid use of drugs that interfere with platelet production: NSAIDs, aspirin, ibuprofen, naproxin *administer stool softeners to prevent straining w/bm *move and turn patient gently to avoid bruising *instruct patient to blow nose gently and only when necessisary *advise patient to consult with HCP regarding safety of sexual intercourse Sickle Cell Anemia pathopysiology - CORRECT ANSWER inherited anemia in which RBCs have a specific mutation that makes the Hgb very sensitive to oxygen changes; any time a decrease in the oxygen tension is sensed the cells begin an observable physical change from their usual shape to a sickle or crescent shape; very rigid and easily cracked and broken; abnormal shape causes cells to be tangled in blood vessels and organs resulting in congestion, clumping, and clotting; gallstones may develop, spleen and liver may enlarge; life span goes from 120 days to 10 to 20 days Sickle Cell Anemia etiology - CORRECT ANSWER an autosomal recessive hereditary disorder; both parents pass on the abnormal Hgb= child will have the disease; if one parent passes on the abnormal Hgb=child will have the trait and not the disease, but will pass the trait on to his/her child Sickle Cell Anemia signs and symptoms - CORRECT ANSWER changes happen on a daily basis; rapid return of oxygen level to normal usually returns the cells to their normal shape; as sickling occurs blood flood becomes sluggish, collects in capillaries, veins, joints, chest, abdominal organs which can cause necrosis which cause pain, fever, swelling; Sickle Cell Anemia Diagnostic tests - CORRECT ANSWER Sickledex test shows sickling of RBCs when oxygen tension is low; Hgb electrophoresis used to determine presence of Hgb S; decreased amount of Hgb, RBC, ESR, elevated WBC Sickle Cell Anemia Therapeutic measures - CORRECT ANSWER treatment depends on severity; receive education on how to prevent crises, supportive care when crises occur; low dose penicillin to prevent infections, acute crises=hospitalization; blood transfusion, oxygen therapy, IV fluids, antibiotics, bone marrow transplant Sickle Cell Anemia Nursing process - CORRECT ANSWER in patient in crisis, assess circulation in extremities every 2 hours, pulse ox, cap refill, peripheral pulses, temperature, monitor neurological status, frequent pain assessment Polycythemia Pathophysiology and Etiology - CORRECT ANSWER includes two separate disorders that are easily recognizable by similar characteristic changes in the RBC count; in both cases the blood becomes so thick with too many RBCs that it resembles sludge Polycythemia vera (PV) - CORRECT ANSWER primary polycythemia; most people have a specific genetic mutation; RBCs, platelets, WBCs are all overproduced; bone marrow packed with too many cells; overabundance spills into general circulation; organs become congested with cells, tissues packed with blood; over age of 50 secondary polycythemia - CORRECT ANSWER result of long term hypoxia; pulmonary diseases, COPD, cardiovascular problems such as chronic heart failure, living in high altitudes, smoking; compensatory mechanism rather than an actual disorder Polycythemia Diagnostic test - CORRECT ANSWER based on CBC and bone marrow aspiration; Lab tests show a Hgb greater than 18 mg/dL, RBC greater than 6 million, and Hct greater than 55%, low level or erythropoietin, bone marrow may show JAK2 (janus kinase) Polycythemia Therapeutic measures - CORRECT ANSWER treatment takes place in 2 stages; first stage decrease the hyperviscosity problem with therapeutic phlebotomy; from 300-500 mL of blood is removed once or twice a week; repeated phlebotomies cause iron deficiency; this in turn stabilizes RBC production; reduce phlebotomies to every 2-3 months; low dose aspirin reduces risk of blood clots; remaining problem is increased WBC which is treated with chemotherapeutic agents or radiation therapy Polycythemia Nursing management - CORRECT ANSWER explain phlebotomy procedure, reassure patient treatment will relieve symptoms; same procedure as donating blood; patient should remain active and ambulatory to prevent thrombosis; monitor patient for complications such as hypovolemia and bleeding; with enlarged liver or spleen offer several small meals each day Polycythemia Patient education - CORRECT ANSWER instruct patient to drink at least 3 L of water daily to reduce blood viscosity; encourage smoking cessation, avoid tight, restrictive clothing, elevate feet when resting to promote good circulation; use support hose; if using anticoagulant or antiplatelet instruct patient of side effects and routine lab tests; Disseminated Intravascular Coagulation (DIC) Pathophysiology - CORRECT ANSWER involves a series of events that results in severe hemorrhage; a catastrophic overwhelming state of accelerated clotting throughout the peripheral blood vessels; in a short period, all of the clotting factors and platelet supplies are exhausted and clots can no longer be formed; results in bleeding from nearly every bodily route possible; not a disease, a syndrome Disseminated Intravascular Coagulation (DIC) Etiology - CORRECT ANSWER can develop after any condition in which the body has sustained major trauma; overhelming infection, obstetric complication, cancer-related causes: leukemia or lung cancer; massive tissue necrosis found in severe crush or burn injuries Disseminated Intravascular Coagulation (DIC) Signs and Symptoms - CORRECT ANSWER abnormal bleeding without a history of a serious hemorrhagic disorder; ecchymoses, petechiae, bleeding from venipuncture sites, IV sites, skin tears, surgical sites, incisions, GI tract, oral mucosa; joints become painful, enlarged, nausea, vomiting, dyspnea, oliguria, convulsions, coma, shock major organ system failure, severe muscle, back and abdominal pain Disseminated Intravascular Coagulation (DIC) Diagnostic tests - CORRECT ANSWER prolonged PT and PTT, decreased platelet count, increased evidence of fibrin degradation products, decrease in Hgb, BUN, Serum creatinine levels increased Disseminated Intravascular Coagulation (DIC) Therapeutic measures - CORRECT ANSWER depends on early recognition of the condition; correct underlying cause; supportive interventions, administration of blood, fresh frozen plasma, platelets, vitamin K, infusion of cryoprecipitate Disseminated Intravascular Coagulation (DIC) nursing management - CORRECT ANSWER early intervention requires vigilance in recognizing and reporting signs of bleeding; focus on prevention of further bleeding episodes; avoid any trauma that might cause bleeding, be careful not to dislodge clots Disseminated Intravascular Coagulation (DIC) patient education - CORRECT ANSWER explain all diagnostic tests; prepare family for what patient may look like in terms of bleeding bruising, equipment in place; enlist aid of social workers, chaplains, other members of health care team Hemophilia Pathophysiology - CORRECT ANSWER two most common are A (classic) and B (Christmas disease) Von Willebrand disease is another related disorder; A (classic) accounts for 80% of all types; results from a deficiency of factor VIII; B is a factor IX deficiency; after an injury the person forms a platelet plug at the site of injury; the clotting factor deficiency keeps the patient from forming a stable fibrin clot Hemophilia Etiology - CORRECT ANSWER Hemophilia A and B are inherited as X-linked recessive traits; the female carrier has a 50% chance of transmitting the gene to each son or daughter; daughters who receive the gene are carriers; sons who receive the gene, have the disease Hemophilia signs and symptoms - CORRECT ANSWER bleeding occurs as a result of injury or in sever cases spontaneously unprovoked by injury; hemarthrosis, bleeding into a joint, is common and can cause acute pain, joint deformities in elbows, knees, ankles; Hemophilia diagnostic tests - CORRECT ANSWER lab data reveal prolong PTT, various clotting factor levels are measured Hemophilia Therapeutic measures - CORRECT ANSWER not curable, treatment aimed at preventing crippling deformities and increasing life expectancy; stop bleeding episodes by administering missing clotting factor; nursing process for patient with hemophilia - CORRECT ANSWER assess patient and family for knowledge of the disease, its treatment, and understanding of how to prevent bleeding episodes; most patients care for themselves at home, start their own IVs and administer treatment; hospitalization is needed only for surgery or major trauma; monitor Hgb and Hct levels; monitor factor VIII and IX levels; monitor vital signs for falling bp, rising pulse=hypovolemic shock; assess all body systems for signs of bleeding; pain assess Acute Pain related to bleeding into tissues - CORRECT ANSWER *have the patient report the location, intensity, and quality of the pain *administer opioids as prescribed, including PCA *avoid the administration of IM injections *reassess the level of pain after administration of analgesia; IV will work almost immediately, oral meds may take 30-60 min *monitor sedation and respiratory status of the patient receiving opioids for pain; opioids depress the respiratory center of the brain Risk for Bleeding related to factor deficiencies - CORRECT ANSWER *instruct the patient on bleeding precautions and signs and symptoms of bleeding *assist with administration of factor concentrates, fresh frozen plasma, cryoprecipitate, blood, or a combination of these as ordered *apply ice or pressure on bleeding sites *avoid IM, subcut, or rectal medications *instruct the patient that preventative care will be needed if surgery or dental procedures are needed *instruct the patient to obtain emergency care in the event bleeding occurs *instruct the patient and families on community services and hemophilia treatment centers available to the patient lean red meats - CORRECT ANSWER foods that will best help provide dietary iron for a patient who has iron-deficiency anemia to correct clotting problems - CORRECT ANSWER why an injection of vitamin K is ordered before surgery for a splenectomy febrile nonhemolytic - CORRECT ANSWER the nurse is caring for a client receiving a blood transfusion who suddenly develops a fever, chills, headache, and back pain. The nurse recognizes this as which type of reaction? initiate bleeding precautions - CORRECT ANSWER The nurse is caring for a client with a platelet level of 10,000/mm3. Which intervention will the nurse implement? sickle cell anemia - CORRECT ANSWER Which disease process causes an accelerated destruction of red blood cells? monitor the site for bleeding and infection - CORRECT ANSWER The nurse is caring for a client who underwent a bone marrow biopsy. Which intervention will the nurse implement following the procedure? The nurse is caring for a client with polycythemia vera (PV). Which clinical manifestation can the nurse expect to find? - CORRECT ANSWER Tinnitus The nurse is caring for a client with pancytopenia who reports dyspnea upon exertion. Which condition will the nurse assess further? - CORRECT ANSWER anemia petechiae, painful joints, dyspnea, abnormal bleeding - CORRECT ANSWER The nurse is caring for a client who is in disseminated intravascular coagulation (DIC). Which clinical manifestations will the nurse expect to find? prolonged prothrombin time (PT) - CORRECT ANSWER The nurse is reviewing lab values for a client experiencing disseminated intravascular coagulation (DIC). Which of these conditions will the nurse expect to find? The nurse is caring for a client with thrombocytopenia. Which bleeding precautions will the nurse implement? - CORRECT ANSWER avoid IM injections Encourage use of slippers when out of the bed Keep the area free of clutter Instruct the client to blow nose only when necessary The nurse is preparing to administer red blood cells (RBCs) to a client with anemia. Which interventions should the nurse implement? - CORRECT ANSWER Transfuse each unit over 4 hrs, and no more than 4 units Use tubing that contains a filter Use two nurses to verify the blood is being transfused to the right client STOP TRANSFUSION & Notify HCP for orders - CORRECT ANSWER The nurse is caring for a client receiving blood transfusion. The client suddenly develops chest pain, frothy sputum, distended neck veins, and crackles. Which action will the nurse take? Hematologic Disorders - CORRECT ANSWER patients with hematologic disorders have problems related to their blood: 1) when RBC's are affected oxygen transport is affected, causing symptoms related to poor oxygenation 2) when WBC's are affected the pt is unable to effectively fight infection 3) If platelets or clotting factors are affected bleeding disorders occur Anemia - CORRECT ANSWER condition in which there is a *deficiency of RBC's, hemoglobin or both in the circulating blood*, hemoglobin carries oxygen this results in a reduced capacity to deliver oxygen to the tissues. Patho: 1) impaired production of RBCs as in aplastic anemia and nutrition deficiencies 2) increase destruction of RBC's as in hemolytic or sickle cell anemia 3) massive or chronic blood loss *WHAT HAPPEN* Diet deficiencies: Iron, Folic acid, and Vitamin B12 are all essential to the production of healthy RBC's a deficiency of any of these nutrients can cause anemia *SIGNS AND SYMPTOMS* 1) Pallor 2) Tachycardia 3) Tachypnea, irritability, fatigue and shortness of breath this occurs due to reduced number of rbc's and reduced ability to carry oxygen to tissues *patients with pernicious anemia will experiences numbness of hands and feet and weakness because Vitamin B12 is needed for normal neurological functions, sore beefy tongue* *patients with iron deficiency may have fissures at the corners of the mouth and inflamed tongue (glossitis) and spoon shaped finger nails* *Dx Test* CBC complete blood count Hemolysis - CORRECT ANSWER *destruction of RBCs or lysis of red blood cells which leads to a type of anemia called hemolytic anemia *this can be congenital disorder or exposure to certain toxins Anemia Treatments - CORRECT ANSWER STOP the cause of anemia if its dietary change cooking habits and intake the correct nutrients, supplements *Nursing Process for pts with Anemia* 1) monitor hemoglobin (Hgb) and hematocrit levels, report any downward trend in labs 2) monitor responses to therapy, pts fatigue level, pts ability to ambulate safely and perform activities of daily living 3) Monitor degree of hgb levels, oxygen saturation, assess for pallor int he skin and conjunctiva *Nursing Dx, Planning, and Treatment* 1) monitor vital signs and tolerance to activity 2) if pulse and respiratory rate increases more than 20% from baseline during activity reduce activity level, also plan to conserve energy during activities 3) give oxygen if dyspnea occurs, assist with blood transfusions as ordered if hgb levels is to low or symptoms are severe Aplastic Anemia - CORRECT ANSWER *the bone marrow does not produce enough rbc's and it then becomes fatty known as "hypoplastic anemia"* *WHAT HAPPEN* 1) aplastic anemia maybe congenital 2) exposure to toxins such as benzenes and insecticides,* chemo meds or cardiopulmonary bypass during surgery* 3) viral or bacterial infections such as TB, Hepatitis, Autoimmune disease *SIGNS AND SYMPTOMS* 1) weakness, fatigue, pallor 2) dyspnea, headache 3) *Ecchymosis (blood leaks from a broken capillary into surrounding tissue under the skin;Bruises are typically caused by an injury such as a fall or a knock)* 4) *Petechiae (are pinpoint, round spots that appear on the skin as a result of bleeding* it may appear red, brown or purple. commonly appear in clusters and may look like a rash. Usually flat to the touch, they don't lose color when you press on them.) 5) Frank-bleeding 6) Infection and DEATH *Dx Testing* 1)CBC complete blood count 2)*Most definitive test is a Bone Marrow Biopsy "the results if often described as a dry tap which pale fatty yellow fibrous marrow is normally seen"* 3)Total Iron Binding Capacity (TIBC) and Serum Iron Level its very common to find these two test levels are elevated since RBCs are not being produced *TREATMENT MEASURES* 1) *most effective treatment is bone marrow transplant* 2) Steroids to stimulate production of cells in weakened bone marrow 3) Colony Stimulating Factors (Epogen/Neupogen) they stimulate the production of WBC's Pancytopenia - CORRECT ANSWER reduced numbers of all formed elements of the bone marrow, RBC's, platelets, and WBC's is the indicator that something is wrong with the bone marrow if not treated death will occur Sickle Cell Anemia (SCA) - CORRECT ANSWER *an inherited anemia in which rbcs have a specific mutation that makes the hemoglobin in the cells very sensitive to oxygen changes* anytime a decrease in oxygen tension is sensed the cells begin an observable physical change from their usual spherical shape to a sickle or crescent shape they are very rigid, and crack easily and break *Dx Test* 1) Sickledex Test is a screening test that shows sickling of rbs when oxygen tension is low 2) hemoglobin electrophoresis is a test used to determine the presence of hemoglobin (Hgb) S shows the abnormal form of hemoglobin, also the decreased amount of hgb also lowers rbc count and an elevated wbc count is seen 3) Erythrocyte Sedimentation Rate (ESR) *TREATMENT MEASURES* 1) Low dose oral penicillin to prevent infections triggered by crisis 2) Pain management and blood transfusions to replace sickled red cells lost by their being caught,crushed, and destroyed 3) Oxygen treatment relieves dyspnea caused by anemia and large amounts of fluids to flush kidneys due to broken cell debris 4) Exjade-deferasirox is a medication that is given to decrease the excess iron levels Corticosteroids may reduce the need for pain meds and oxygen 5) Hydroxyurea (Droxia) is a med used to decrease crisis *Nursing Dx* 1) encourage fluids to dilute and help in elimination of cell debris 2) apply a warm compress using on painful areas 3) avoid cold compresses because they decrease circulation 4) avoid restrictive clothing and raising the knee gnatch of the hospital bed which can impair circulation 5) administer pain meds such as Morphine for acute pain, Tylenol to control fever, *avoid aspirin which do lead to acidosis* 6) encourage bed rest during crisis to reduce oxygen demand Sickle Cell Crisis Signs/Symptoms - CORRECT ANSWER red blood cells are sensitive to oxygen changes crescent shaped, and they clump together in the body blood volume and clog blood circulation obstruction of capillary flow, and wide spread pain due to occlusion therefore oxygen is not delivered to body organs hand and food syndrome develops where different lengths of fingers and toes Polycythemia - CORRECT ANSWER this is an overabundance of rbc that is closely resembles sludge, this thickness does not allow the blood to circulate, LAB test shows a hgb level greater than 18mg/dL an RBCs mass greater than 6 million and a hematocrit of more than 55% the rbc,platelets, and wbc are all overproduced and the bone marrow becomes packed with too many cells usually found in pts over 50 yrs pts to secondary polycythemia is the result of long hypoxima, COPD cardiovascular problems such as chronic heart failure, living in high altitude and smoking, secondary polycythemia is a compensatory mechanism rather than an actualy disorder Polycythemia Vera (PV) - CORRECT ANSWER the red blood cell, platelets and white blood cells are all overproduced and the bone marrow becomes packed with too many cells with this overabundance the cells spill out into the general circulation which cause the organs to become congested which becomes packed with blood. the skin takes on a plethoric "dark flushed appearance" from the buildup of red cells the thick blood and excess platelets can cause thrombosis and occlusion of vessels its found in pts over 50 yrs old Polycythemia signs and symptoms - CORRECT ANSWER *long term polycythemia results in hypoxia(deficiency in the amount of oxygen reaching the tissues)* Hypertension, vision changes, headache, vertigo, dizziness, tinnitus),spleenomegaly Lab values shows panmylelosis an increase level of all bone marrow components(rbc's, wbc's, platelets) Extreme case develops thrombocytopenia also at risk for a bleeding disorder called acquired von Willebrand syndrome this pt will develop nosebleeds, bleeding gums, retinal hemorrhages, exertional dyspnea, chest pain due to increased pressure exerted excess cells *Dx Test* diagnosis of polycythemia pv is done by a CBC blood test, bone marrow aspiration low level of erythropoietin is present due to negative feedback to the kidneys *Treatment Measures* *First stage is to decrease the hyper-viscosity problem which is to complete a phlebotomy which involves withdrawal of blood about 350-500 mL* is removed each time on every other day basis *Second stage treatment is chemotherapeutic agents or radiation therapy including radioactive phosphorus* may be used to suppress production of blood cells in some pt. Leukemia is a side effect of this treatment Low dose aspirin *Nursing Dx* 1) *drink 3 Liters of water daily to dilute blood* 2) avoid tight clothing, elevate feet 3) report s/s of iron deficiency, bleeding 4) *remain active to prevent thrombus and use support hose to promote circulation* Disseminated Intravascular Coagulation (DIC) - CORRECT ANSWER disseminated intravascular coagulation involves a series of events that ends in severe hemorrhage, catastrophic overwhelming state of accelerated clotting throughout the peripheral blood vessels, all clotting factors and platelet supplies are exhausted and clots can no longer be formed which bleeding results in every part of the body this is a syndrome which results progression of symptoms is rapid *WHAT HAPPEN* 1) a source of bad trauma, an overwhelming infection, obstetric complication such as abruptio placenta, amniotic fluid embolism 2) retained dead fetus 3) cancer related causes such as acute leukemia or lung cancer 4) Burns *SIGNS AND SYMPTOMS* 1) abnormal bleeding 2) nausea and vomiting 3) organ system failure due to massive clotting 4) convulsions, shock and coma 5) death 6) easy bruising, and petechiae 7) blood in urine, black tarry stool 8) bleeding from on set and gums 9) new onset of painful joints *DX TEST* 1) prolonged prothrombin time (PT) and partial thromboplastin time (PTT) 2) decreased platelet count and increase evidence of fibrin 3) decrease in hemoglobin, BUN, serum creatinine levels may increase *Nursing Management* 1) EARLY INTERVENTION 2) avoid trauma and further bleeding Bleeding Precautions (RANDI) - CORRECT ANSWER R- Razor Electric/ Blades A- Aspirin N- No needles (esp. in small gauge) D- Do decrease in needle sticks) I - Injury (Protect from) and NO Intramuscular Injections Administer Stool Softener Hemophilia - CORRECT ANSWER A hereditary disease where blood does not coagulate to stop bleeding 2 most common are hemophilia A (classic hemophilia) and hemophilia B (Christmas disease) Von Willebrand's disease is another related bleeding disorder *PATHOPHYSIOLOGY* 1) missing clotting factors A factor 8 classic hemophilia 80% of cases B factor 9 Christmas disease *WHAT HAPPEN* 1) heredity girls are carriers and boys have the disease. *SIGNS/SYMPTOMS* 1) *spontaneous bleeds into the joints causes pain* 2) muscles is a "hemarthrosis", subcutaneous tissue 3) Brain *DX TEST* 1) prolonged PTT various clotting factor levels 2) Factor 8 hemophilia A 3) Factor 9 hemophilia B *TREATMENT MEASURES* 1) hemophilia is not curable 2) administer the missing clotting factors 3) Desmopressin DDAVP, anti-diuretic hormone which stimulates the body to release more clotting factors 4) More severe hemophilia A is treated with factor 8, factor 9 these treatments are reconstituted with water and given via IV treatment Multiple Myeloma (MM) - CORRECT ANSWER *deadly cancer of the plasma cells in bone marrow due to bone destruction and pathological fractures* *Pathophysiology* cancerous plasma cells in the bone marrow begin reproducing uncontrollable, these cells infiltrate bone tissue all over the body and produce many tumors that begin to devour the bone tissue. multiple myeloma usually affects the bones of the skull, pelvis,ribs and vertebrae, as the disease progress, plasma cells get into organs, such as the liver,spleen, lymph nodes, lungs, kidneys it causes widespread osteoporosis, death is often from SEPSIS *WHAT HAPPEN* Unknown or Occupational Exposure *SIGNS/SYMPTOMS* Greatest complaint is bone pain fever, malaise,spinal cord compression pathological fractures, Hypercalcemia Cancer leaves bones and spreads to vital organs, SEPSIS kills pt. *DX TEST* 1) CBC, blood calcium 2) Bone X-rays, checking for holes 3) MRI of bones checking for osteoporosis 4) Urine for Bence Jones Protein (immunoglobulin) this is not normally found in urine 5) Bone Marrow Biopsy *TREATMENT MEASURES* 1) First approach is steroid use 2) *Chemo treatment (Velcade bortezomib is a protease inhibitor that stops enzymes to disrupt cancer cell growth and survival)* 3) Control of Serum Calcium give Phosphate 4) Radiation 5) Stem Cell Transplantation 6) *Thalidomide IV chemo given to slow the progression of the disease Lanalidomide (Revlimid) is chemically similar to Thalidomid* but has fewer side effects the goal of the drug is to suppress plasma cell proliferation which helps in bone destruction *Nursing Dx* 1) Risk for infection 2) Risk for injury 3) fracture,complication of immobility, hypercalcemia Non-Hodgkin's Disease (NHL) - CORRECT ANSWER *cancer of the lymph* very curable in early stages * most important is the difference is the absence of the Reed Sternberg cells* instead many lymphomas arise from the B cells and T cells. B cells are involved in recognizing and destroying specific antigens these cells include the B cells and Plasma cells T cells are involved in registering antigens *WHAT HAPPEN* they can develop from H.Pylori bacteria and Epstein-Barr, Herpes Virus Genetics and immune problems such as AIDS Occupational hazardous people working in the farming,printing,medicine,electronics and leather have high risk for developing non Hodgkin lymphoma *Sign/Symptoms* painless swollen lymph nodes puritis (itchy skin) fever, night sweats,weight loss, malaise *LATE SIGNS AND SYMPTOMS* 1) edema of face and neck 2) jaundice, nerve pain 3) retro-peritoneal node involvement 4) spleen, liver, and bone involvement *DX TEST* biopsy of lymph node,liver and spleen also bone marrow Ct-Scan, Chest X-ray, Lungs Bone Scan Lymphangiography CBC *TREATMENT MEASURES* Chemotherapy and Radiation Therapy *Nursing Dx* impaired comfort activity intolerance, risk for infection risk for ineffective coping Hodgkin's lymphoma (HL) - CORRECT ANSWER *important feature is the presence of Reed stenberg cells which makes it different from all other forms of lymphoma its the most curable* MI's and dysrhythmias: what is happening? - CORRECT ANSWER •A MI occurs as a result of sustained ischemia causing irreversible myocardial cell death. Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration is the hallmark of an MI. Persistent and unlike any other pain; it is usually described as heaviness, pressure, tightness, burning, constriction, or crushing. Usually lasts 20 min. Pain may radiate to neck, jaw, and arms or back. What diagnostic tests are done and what do they tell you? - CORRECT ANSWER •ECG: Measures electrical activity of the heart. Can identify areas of necrosis and ischemia. •Blood tests: After an MI, proteins are released into the blood from necrotic heart muscle. Indicates if cardiac damage has occurred. oCK increased 3-12 hours after initial damage, peaks at 24 hrs, and returns to normal in 2-3 days. oTroponin is more specific than CK. Troponin increases within 3-12hrs, peaks at 24-48 hrs, and returns to normal in 5-14 days. Coronary angiography - CORRECT ANSWER Cardiac cath that locates blockage, assesses severity, evaluates function of left ventricle. What is PCI? - CORRECT ANSWER Percutaneous Coronary Intervention (PCI) aka heart cath or balloon angioplasty, uses local anesthesia and has a faster recovery than CABG. This procedure is when a cath equipped with an inflatable balloon tip is inserted into the appropriate coronary artery. When the blockage is located, the balloon is inflated, and the plaque is compressed, resulting in vasodilation. UH or LMWH is given in conjunction with PCI to maintain the open vessel. Intracoronary stents are often inserted in conjunction with PCI. What are nursing interventions after a PCI? - CORRECT ANSWER •After procedure, assess circulation to extremity used for cath insertion. •Check peripheral pulses, color, and sensation of extremity q15 min for 1hr with decreasing frequency. •Observe puncture site for hematoma and bleeding. •Place compression device over arterial site if indicated. •Monitor VS. •Assess for abnormal HR, dysrhythmias, and signs of PE (respiratory difficulty). What meds are given for MI and why? - CORRECT ANSWER •Fibrinolytics: •Aspirin •Morphine •Nitroglycerin •B Blockers •ACE Inhibitors •Stool softeners What is appropriate activity post-MI? - CORRECT ANSWER •While the pt is in the hospital, activity level depends on severity of angina or MI. Pt may sit up in chair, perform ROM exercises and self-care, and progress to ambulation in the hallway and limited stair climbing. •After discharge, weeks 2-12, activity level is gradually increased under supervision of the cardiac rehab team and ECG monitoring. The team may suggest physical activity be initiated at home. •For long term maintenance, individual physical activity programs are designed and implemented at home, a local gym, or the rehab center. What complications would you monitor for? - CORRECT ANSWER •Dysrhythmias-damaged heart cells are more sensitive to nerve impulses. • HF-damaged heart muscle can't work as well. •Cardiogenic shock-left ventricle fails and can't get enough O2 to tissues. • Mitral Valve regurgitation-if damage occurs near papillary muscle attached to valve, leads to increased blood volume in left atrium and decreased CO. •Ventricular Aneurysm-damaged heart wall is thinner and bulges with contractions. •Pericarditis-inflammation of pericardium, may compress heart, occurs 2-3 days post MI, causes stabbing chest pain relieved by sitting forward. •Tachycardia and Bradycardia can occur because there are disruptions in the normal pathways of the heart. What is CABG? - CORRECT ANSWER Coronary Artery Bypass Graft is the use of vessels from the pts body placed into the heart to bypass occlusion and transport blood to the myocardium distal to the occlusion. The chest is opened (sternotomy) and the patient is placed on cardiopulmonary bypass. Ongoing and intensive monitoring of hemodynamic status is critical. What is nursing care post op? - CORRECT ANSWER •The pt will have numerous invasive lines for monitoring cardiac status and other vital organs including: pulmonary artery catheter, intraarterial line, pleural and mediastinal chest tubes, continuous ECG, endotracheal tube, epicardial pacing, urinary catheter, and an NG tube. •Assessing the pt for bleeding, monitor fluid status, replacing electrolytes, and restoring temperature are primary nursing tasks. •Caring for the surgical sites. Teaching for CABG? - CORRECT ANSWER The pt activity must be increased slowly while being monitored. The HR should NOT increase more than 20bmp from baseline during activity. If it does, they're overdoing it. What if pt develops bradycardia--what is the treatment and why? - CORRECT ANSWER •Bradycardia is usually caused by vagus nerve stimulation. •If it is asymptomatic the patient is assessed and monitored. •If it symptomatic the patient is given 1 mg of atropine IVP. Atropine stops the stimulation the vagus nerve. "Mechanical Scissors". •Long-term treatment is a pacemaker. When might bradycardia be normal finding? - CORRECT ANSWER •The resting heart rate of an athlete may be bradycardic. What treatments might be used for tachycardia? - CORRECT ANSWER •Adenosine-stops the heart momentarily before it restarts it with a lower heart rate. •Vagal maneuvers. What are PVC's? - CORRECT ANSWER •Premature Ventricular Complexes- early beat that originates in the ventricle. •QRS will be wider than usual on the ECG strip. •Dangerous when they are more frequent than every 6 minutes, coupled, multifocal or R-on-T (PVC following closely on T-wave of the previous beat). •Assess for a pulse deficit. If one is present, the pulse will be different at the apical pulse then at a peripheral pulse. What are possible causes of PVC's? - CORRECT ANSWER Usually due to irritable area in the ventricles or electrolyte imbalances (potassium). How would you treat PVCs? - CORRECT ANSWER •Treatment is lidocaine or amiodarone. What is pericarditis? Most common cause? - CORRECT ANSWER Inflammation of the pericardium (outer layer of the heart). Usually caused by the Coxsackie virus. What are symptoms of pericarditis? - CORRECT ANSWER Chest pain, dysphagia (diff swallowing), restlessness, irritability, anxiety,PERICARDIAL FRICTION RUB, and weakness. What are causes of pericarditis? - CORRECT ANSWER Surgery, infection, connective tissue disease, radiation therapy, uremia (toxins not excreted by the kidneys), MI, TB. What is the treatment for pericarditis? - CORRECT ANSWER •Relieve the symptoms, treat pain, rest, salicylates (aspirin), raise the head of the bed, and NSAIDS. •Monitor for complications such as pericardial effusion and cardiac tamponade. •Monitor for decreased CO •Usually is self-limiting. Regurgitation--what is it? - CORRECT ANSWER Insufficiency or incompetence of the valve leaflets or valve cusps. They fail to shut completely and allow blood flow to continue when it shouldn't. What is important teaching for regurgitation? - CORRECT ANSWER •Since many patients are asymptomatic for years, it is important to teach them the S/S of pulmonary edema and shock for mitral valve regurgitation. •For aortic valve regurgitation it is important to teach them the S/S of left ventricular failure, shock, and cardiovascular collapse. Stenosis--what is it? - CORRECT ANSWER It is the narrowing or constriction of the valve by adhesions (scarring) or by thickening and shortening of the leaflets in the valve. What is the nursing care for stenosis? - CORRECT ANSWER •Prevention of exacerbations of HF, pulmonary edema, thromboembolism, and recurrent endocarditis. •Anticoagulant therapy is used as prevention and treatment for PE. •Dysrhythmias are treated with meds or cardioversion. What problems can stenosis of the aortic valve cause? - CORRECT ANSWER Aortic valve stenosis can cause the LEFT VENTRICLE HYPERTROPHY, heart failure, and pulmonary hypertension. With mitral valve stenosis---what is complication (symptom) that a nurse should assess for? - CORRECT ANSWER •Fluid overload. •Pulmonary hypertension is a concern since the pressure impacts the pulmonary vessels. •Seizures or a stroke from emboli can result from blood stasis in the LEFT ATRIUM. Valve replacement--what is important teaching? - CORRECT ANSWER •Mechanical or biological replacement of a damaged valve using a prosthetic valve. •The most important teaching is anticoagulation therapy. They must realize that this surgery is NOT A CURE, and that regular follow up with their health care provider is mandatory. •Teach pt to seek medical care when signs of infection, Heart failure, or any signs of bleeding occur. •MUST TAKE ANTIBIOTICS before invasive or dental procedures and wear a medic alert bracelet. Rheumatic fever: What causes it? - CORRECT ANSWER Having an untreated strep infection for 2-3 weeks. (Group A hemolytic streptococcus) What does Rheumatic fever cause? - CORRECT ANSWER •Causes scarring and deformation of cardiac structures or valves (Mitral valve most commonly affected) •S/S: fever, lymphadenopathy, arthralgia, N/V, epistaxis, abdominal pain, tachycardia, carditis, polyarthritis, chorea (involuntary writhing), and erythema marginatum lesions on the body. How can you decrease incidence of Rheumatic fever? - CORRECT ANSWER Get a throat culture to test for strep A pharyngitis and treat with oral PCN or erythromycin. What is important teaching for the patient with it? - CORRECT ANSWER To teach pt about recurrence. Once you have it, you are more susceptible to a second reoccurrence. These patients should be taught about the disease process, possible sequelae (a condition following a disease), and continual need for prophylactic antibiotics. What are risk factors for Infective Endocarditis? - CORRECT ANSWER •Inflammation of the endocardium (inner lining of the heart). • Risk Factors: acquired valvular heart disease, prosthetic heart valves, previous history, male gender, age, IV drug use(IVDA), long term catheter use(renal dialysis), or cardiac surgery. (Bacteria in the bloodstream) What is important teaching for infective endocarditis? - CORRECT ANSWER •Teach on the symptoms of recurrence. Teach to stay away from people with infections especially upper respiratory infections (URI), and to report cold/flu/cough symptoms. •Teach patient the S/S of emboli and dysrhythmias. •Avoid excessive fatigue and plan rest periods. •Perform good oral hygiene •The need for prophylactics before invasive and dental procedures. How do you calculate Cardiac Output? - CORRECT ANSWER •Cardiac output is the amount of blood pumped by the left ventricle in one minute. You calculate cardiac output by multiplying the stroke volume by the heart rate (in one minute). •The normal cardiac output for the normal adult at rest is 4-8L/min. What is preload? - CORRECT ANSWER the volume of blood in the ventricles at the END OF DIASTOLE. Could also be defined as the amount of stretch placed on the heart between each beat. •Increases with exercise. What is afterload? - CORRECT ANSWER the peripheral resistance against which the left ventricle must pump or the amount of pressure that the heart must pump against. •Increases with HTN, and aortic stenosis. How do preload and afterload affect cardiac output? - CORRECT ANSWER •Both preload and afterload increase the workload of the heart resulting in an increased oxygen demand. What does peripheral vascular resistance have to do with any of it? - CORRECT ANSWER Peripheral vascular resistance increases afterload which in return decreases cardiac output. What do the P wave, the PR-Interval, and the QRS complex on the ECG indicate is happening? - CORRECT ANSWER The P wave begins with the firing of the SA node and indicates depolarization of the atria (or contraction of the atria) The PR-interval indicates the amount of time it takes for the electrical impulse to travel from the SA node to the AV node. The QRS complex represents the depolarization of the ventricles or contraction of the ventricles. What is the pacemaker of the heart and its rate? - CORRECT ANSWER The pacemaker of the heart is the SA node and sustains a rate of 60-100 bpm What about the SA node's backups? - CORRECT ANSWER •The first back-up is the AV node that sustains a rate of 40-60 bpm. •The last back-up pacemaker the heart has is the Purkinje fibers. They can sustain a rate of 20- 40 bpm. What are symptoms of decreased cardiac output? - CORRECT ANSWER The symptoms of decreased cardiac output include decreased blood pressure, increased heart rate, decreased oxygen saturation, labored breathing, decreased capillary refill, cyanosis, decreased urine output, pale and diaphoretic. How do you quickly determine the heart rate by looking at a rhythm strip? - CORRECT ANSWER To quickly assess the heart rate from an individual's rhythm strip count the beats in between 2 hash marks on the top of the strip and then multiply by ten. Fibrinolytics - CORRECT ANSWER "clot busters" IV meds to dissolve clot and allow reperfusion (Give within 6hr of onset of pain/sx) Aspirin - CORRECT ANSWER antiplatelet and analgesic Morphine - CORRECT ANSWER IV analgesic, vasodilator, decreases workload of the heart Nitroglycerin - CORRECT ANSWER may be sublingual, up to 3 tabs q5min or until pain relieved. Works to decrease preload and afterload, vasodilator, increases O2 to myocardium, decreases pain, increases blood flow. Immediate onset. B Blockers - CORRECT ANSWER decrease hearts demand for O2, Decreases HR and BP ACE Inhibitors - CORRECT ANSWER given post MI to decrease HF if left ventricular dysfunction Stool softeners - CORRECT ANSWER prevent constipation and straining Cardiogenic shock - CORRECT ANSWER left ventricle fails and can't get enough O2 to tissues Mitral Valve regurgitation - CORRECT ANSWER if damage occurs near papillary muscle attached to valve, leads to increased blood volume in LEFT ATRIUM and decreased CO. Ventricular Aneurysm - CORRECT ANSWER damaged heart wall is thinner and bulges with contractions Atropine - CORRECT ANSWER Stops vagus nerve stimulation Cardiac Output - CORRECT ANSWER amount of blood ejected from the left ventricle in one minute stroke volume x heart rate = Stroke Volume - CORRECT ANSWER amount of blood ejected by a ventricle in one contraction and averages 60 to 80 mL /beat Starling's Law of the Heart - CORRECT ANSWER During exercise, venous return increases and stretches the ventricular myocardium, which in response contracts more forcefully. Which results in an increase in stroke volume. norepinephrine - CORRECT ANSWER Sympathetic nerve impulses - increase rate and force of contraction by releasing _____. acetylcholine - CORRECT ANSWER Parasympathetic impulses - along the vagus nerve to the SA node, AV node, and atrial myocardium - decreases heart rate by releasing _____. baroreceptors - CORRECT ANSWER specialized cells in the carotid and aortic sinuses, detect changes in blood pressure chemoreceptors - CORRECT ANSWER located in the carotid and aortic bodies and are cells specialized to detect changes in the oxygen content of the blood (as well as changes in carbon dioxide and hydrogen ion content). epinephrine - CORRECT ANSWER secreted by the adrenal medulla in stressful situations, is sympathomimetic in that it increases the heart rate and force of contraction and it dilates the coronary vessels aldosterone - CORRECT ANSWER hormone produced by the adrenal cortex, is important for cardiac function because it helps regulate blood levels of sodium and potassium, both of which are needed for the electrical activity of the myocardium potassium - CORRECT ANSWER The blood level of _____ is especially critical because even a small deficiency or excess impairs the rhythmic contractions of the heart atrial natriuretic peptide - CORRECT ANSWER The atria of the heart secrete a hormone of their own called _______ or atrial natriuretic hormone. It increases the excretion of sodium by the kidneys, by inhibiting secretion of aldosterone by the adrenal cortex (Is secreted when a higher blood pressure or greater blood volume stretches the walls of the atria) sodium - CORRECT ANSWER The loss of _____ is accompanied by the loss of more water in urine, which decreases blood volume therefore blood pressure as well. Arteries - CORRECT ANSWER ____ carry blood under high pressure, and the outer layer of fibrous connective tissue prevents rupture of the vessels middle layer - CORRECT ANSWER The _____ of smooth muscle and elastic connective tissue contributes to the maintenance of normal blood pressure, especially diastolic BP, by changing the diameter of the artery. diameter - CORRECT ANSWER The ______ of arteries is regulated primarily by the sympathetic division of the autonomic nervous system smooth muscle - CORRECT ANSWER By use of the ______, the arteries can also alter where the greatest volume of blood is directed. simple squamous epithelium - CORRECT ANSWER The inner layer of the artery is ______, called endothelium, which is very smooth to prevent abnormal clotting. veins - CORRECT ANSWER _____ do not have as important a role in the maintenance of BP as arteries veins and venules - CORRECT ANSWER _____ walls are relatively thin because they have less smooth muscle than arteries severe hemorrhage - CORRECT ANSWER Sympathetic impulses can bring about extensive constriction of veins, however, and this becomes important in situations such as ______. valves - CORRECT ANSWER The lining of veins is, like arteries, endothelium the prevents abnormal clotting; at intervals it is folded into _____ to prevent back flow of blood extremities - CORRECT ANSWER Valves are most numerous in the veins of the ______, especially the legs, where blood must return to the heart against the force of gravity. precapillary sphincter - CORRECT ANSWER Blood flow through a capillary network is regulated by a ________, a smooth muscle fiber ring that contracts or relaxes in response to tissue needs. blood - CORRECT ANSWER The body does not have enough _____ to fill all of the capillaries at once; the fixed volume must constantly be shunted or redirected to where it is needed most. filtration - CORRECT ANSWER Tissue fluid is formed from the plasma in capillaries by the process of ______. 30 to 35 mm Hg - CORRECT ANSWER The blood pressure in capillaries is ______ at the arterial end of the network 15 mm Hg - CORRECT ANSWER The pressure in capillaries drop to about ______ at the venous end of the network pressure - CORRECT ANSWER This _____ is low enough to prevent rupture of the capillaries but high enough to permit filtration lymph - CORRECT ANSWER Some of the tissue fluid returns to the capillaries, and some is collected in ______ capillaries. edema - CORRECT ANSWER Should blood pressure within the capillaries increase, more tissue fluid than usual is formed, which is too much for the lymph vessels to collect. This may result in _____. arterioles - CORRECT ANSWER The ______ (and veins during increased sympathetic stimulation) are usually in a state of slight constriction that helps to maintain normal blood pressure, especially diastolic pressure. This is called peripheral resistance peripheral resistance - CORRECT ANSWER Is regulated by the vasomotor center in the medulla, which generates impulses along sympathetic vasoconstrictor nerves to these vessels' smooth muscle rises - CORRECT ANSWER When the nerves carry more impulses per second to the smooth muscle, vasoconstriction increases and blood pressure ____ lowers - CORRECT ANSWER When the nerves carry impulses per second to the smooth muscle, fewer impulses per second bring about vasodilation and _____ blood pressure atria - CORRECT ANSWER The strength of the heart's contractions depends on adequate venous return, which is the amount of blood that flows into the ______. elasticity - CORRECT ANSWER The _____ of the large arteries also contributes to normal blood pressure force - CORRECT ANSWER When the left ventricle contracts, the blood stretches the walls of the large arteries, which absorb some of the ____. kidneys - CORRECT ANSWER The _____ are of great importance in the regulation of blood pressure. renin - CORRECT ANSWER ______ splits the plasma protein angiotensinogen (from the liver) to form angiotensin I, which is changed to angiotensin II by a converting enzyme found primarily in lung tissue. angiotensin II - CORRECT ANSWER ______ causes arteriole vasoconstriction and stimulates secretion of aldosterone, both of which raise blood pressure. sodium ions - CORRECT ANSWER Aldosterone, secreted by the adrenal cortex, increases the re-absorption of _______ by the kidneys increases - CORRECT ANSWER Water follows the sodium back to the blood; this ______ blood volume and blood pressure. cardiac output - CORRECT ANSWER Other hormones that affect blood pressure include those of the adrenal medulla, norepinephrine and epinephrine, which increase ________ and cause vasoconstriction in skin and viscera. Antidiuretic hormone - CORRECT ANSWER _______, released from the posterior pituitary, directly increases water reabsorption by the kidneys, thus increasing blood volume and blood pressure. blood pressure - CORRECT ANSWER Atrial natriuretic peptide, secreted by the atria of the heart, inhibits aldosterone secretion and thereby increases renal excretion of sodium ions and water, which decreases blood volume and subsequently ______. pulmonary circulation - CORRECT ANSWER ______ begins at the right ventricle, which pumps deoxygenated blood into the pulmonary artery. pulmonary artery - CORRECT ANSWER The ______ branches into two arteries, one to each lung. one-fifth - CORRECT ANSWER The blood pressure in the pulmonary circulation is always low because the right ventricule pumps with only about _____ the force of the left ventricle. pulmonary edema - CORRECT ANSWER The pulmonary arterial pressure is approximately 20 to 25 over 8 to 10 mm Hg, and he pulmonary capillary pressure is lower still. This is important to prevent filtration in pulmonary capillaries, which keeps tissue fluid from accumulating in the alveoli of the lungs, causing _____. systemic circulation - CORRECT ANSWER _______ begins in the left ventricle, which pumps oxygenated blood into the aorta, the many branches of which eventually give rise to capillaries within the tissues. hepatic portal circulation - CORRECT ANSWER The ______ is a special part of the systemic circulation in which blood from the capillaries of the digestive organs and spleen flows through the portal vein and into the capillaries in the liver before returning to the heart. atherosclerosis - CORRECT ANSWER _______ is the deposition of lipids in the walls of arteries over a period of years. cerebral, renal - CORRECT ANSWER Atherosclerosis decreases blood flow to the affected organ; _____ flow can diminished by 20% and _____ flow by 50% by age 80. heart murmur - CORRECT ANSWER Valves may become thickened by fibrosis, leading to ______. one in three - CORRECT ANSWER _______ people in the US have cardiovascular disease and it is the number one killer of people in the United States. smoking - CORRECT ANSWER ______ contributes to approximately one in five cardiovascular disease deaths. older adults - CORRECT ANSWER _______ commonly have signs and symptoms that are not typical of a disorder, such as fatigue and nausea. The only symptom of myocardial infarction in an older patient may be dyspnea. Chest pain, a typical symptom, may not be present. rheumatic fever or scarlet fever - CORRECT ANSWER Childhood illnesses that can lead to heart disease, such as ________, are noted. activities of daily living - CORRECT ANSWER Functional limitations that are related to cardiovascular problems, such as difficulty performing _______, walking, climbing stairs, or completing household tasks, are also assessed. 60, increased - CORRECT ANSWER Patients that have had a parent die of sudden cardiac death before age____ are at _______ risk for sudden cardiac death. higher - CORRECT ANSWER The reading in the leg is normally 10 mm Hg ____ than in the arm. orthostatic hypotension - CORRECT ANSWER Factors that may cause ______ include fluid volume deficit, diuretic, analgesics, and pain regular or irregular - CORRECT ANSWER Apical pulse is documented as _______. normal - CORRECT ANSWER A _____ vessel feels soft and springy sclerotic - CORRECT ANSWER A ______ vessel feels stiff. thrill - CORRECT ANSWER In the abnormal vessel that has a bulging or narrowed wall, a vibration is felt, which is called a ______. bruit - CORRECT ANSWER When auscultating an abnormal vessel, a humming is heard that is caused by the turbulent blood flow through the vessel. This is referred to as a _____. pink frothy - CORRECT ANSWER _______ sputum is an indicator of acute heart failure. pallor - CORRECT ANSWER _____ may indicate anemia or lack of arterial blood flow. dry - CORRECT ANSWER A ____ cough can occur from the irritation caused by lung congestion resulting from heart failure. reddish brown - CORRECT ANSWER A ______ discoloration (rubor) found in the lower extremities occurs from decreased arterial blood flow. brown, cyanosis - CORRECT ANSWER A ____ discoloration and ______ when the extremity is dependent may be seen in the presence of venous blood flow problems. 45 to 90 - CORRECT ANSWER The patient's internal and external jugular neck veins are observed for distention in a _______ degree upright position. right sided - CORRECT ANSWER Distention of internal and external jugular veins indicates an increase in the venous volume often caused by _______ heart failure. peripheral vascular disease - CORRECT ANSWER Pain, poikilothermia, pulselessness, pallor, paralysis, and parestesia (decreased sensation) is the six P's of ________. point of maximum impluse - CORRECT ANSWER The _______ is palpated by placing the right hand over the apex of the heart. If palpable, a thrust is felt when the ventricle contracts. enlarged heart - CORRECT ANSWER A(n) ________ may shift the point of maximum impulse to the left of the midclavicular line. poikilothermy - CORRECT ANSWER In the absence of sufficient arterial blood flow, the area becomes the temperature of the environment this is called ______. 50% - CORRECT ANSWER Homans' sign is an assessment for venous thrombosis; however, in less than ____ of patients with thrombosis, the test is not positive. heart valves - CORRECT ANSWER Normal heart sounds are produced by the closing of the ______. tricuspid and mitral valves - CORRECT ANSWER The first heart sound is heard at the beginning of systole as "lubb" when the _______ close. S4 - CORRECT ANSWER The _____ heart sound is also a low-pitched sound, similar to a gallop but heard later in diastole. It occurs with hypertension, coronary artery disease, and pulmonary stenosis. S3 - CORRECT ANSWER In older adults, ____ may be heard with left-sided heart failure, fluid volume overload, and mitral valve regurgitation (This heart sound is normal for children and young adults. It sounds like a gallop and is a lowpitched sound heard early in diastole) aortic and pulmonic semilunar valve - CORRECT ANSWER The second heart sound is heard at the start of diastole as "dupp" when the ________ close. murmur - CORRECT ANSWER ______ are caused by a narrowed valve opening or a valve that does not close tightly ( it is a prolonged, swishing sound that ranges in intensity from faint to very loud.) pericardial friction rub - CORRECT ANSWER A _______ occurs from inflammation of the pericardium. rub - CORRECT ANSWER A _____ has a grating sound like sandpaper being rubbed together that occurs when the pericardial surfaces rub together during a heartbeat. myocardial infarction or chest trauma - CORRECT ANSWER A pericardial friction rub may occur after a _________. chest x-ray - CORRECT ANSWER A _____ examination shows the size, position, contour and structures of the heart. It can reveal heart enlargement, calcifications, fluid around the heart, heart failure and placement of pacemaker leads and pulmonary artery catheters. CT scanning - CORRECT ANSWER ______ can be used to evaluate the heart, coronary arteries, pulmonary veins, aorta, pericardium and cardiac masses. cardiac MRI - CORRECT ANSWER ______ is useful for identifying ischemia and heart damage as well as other conditions affecting the heart. (Patients with pacemakers, defibrillators, cochlear implant, or brain aneurysm clips are not candidates for this test.) electrocardiogram - CORRECT ANSWER The _______ records electrical activity of the heart in various views. Abnormalities related to conduction, rate, rhythm, heart chamber enlargement, myocardial ischemia, MI and electrolyte imbalances may be reflected. signal averaged ECG - CORRECT ANSWER The _______ is used to diagnose whether a patient is at risk for developing ventricular tachycardia and possible sudden death. echocardiogram - CORRECT ANSWER Abnormalities that may be seen on the ________ include heart enlargement, valvular abnormalities, thickened cardiac walls or septum and pericardial effusion. transesophageal echocardiogram - CORRECT ANSWER A ________ provides a clearer picture than transthoracic echocardiography. It produces images by using a transducer on a probe that is placed in the esophagus. cardiac stress test - CORRECT ANSWER The _______ is used to evaluate coronary artery disease. (This test aids in diagnosing ischemic heart disease, the cause of chest pain and dysrhythmias. The functional capacity of the heart can also be measured after a cardiac event or to plan a physical fitness or rehabilitation program.) claudication - CORRECT ANSWER pain in the legs with activity plethysmography - CORRECT ANSWER A _________ test measures blood volume and changes in blood flow to diagnose deep venous thrombosis and pulmonary emboli and to screen patients for peripheral vascular disease. brachial artery - CORRECT ANSWER Stiffness of the _______ is measured to determine arteriosclerosis and cardiovascular disease risk. arterial stiffness index - CORRECT ANSWER The ________ test is done with a device that has a blood pressure cuff hooked to a computer that maps the waveforms during the blood pressure readings. tilt table - CORRECT ANSWER The ______ test is used to help diagnose the cause of syncope doppler ultrasound - CORRECT ANSWER In a ______ test, sound waves bounce off moving blood cells and return a sound frequency in relationship to the amount of blood flow. nuclear radioisotope imaging - CORRECT ANSWER For _________, small amount so f radioisotopes are given intravenously. The patient is then scanned with a gamma camera to produce a radionuclide image. Tests can provide information about myocardial ischemia or infarction, cardiac blood flow and ventricle size and motion. Thallium imaging - CORRECT ANSWER _______, a radioactive analog of potassium, is used to detect impaired myocardial perfusion. positron emission tomography - CORRECT ANSWER ________ shows myocardial perfusion and viability with three-dimensional images. Nitrogran-13 ammonia is injected IV first and then scanned to show myocardial perfusion. blood lipids - CORRECT ANSWER ______ include triglycerides, cholesterol, and phospholipids. triglycerides - CORRECT ANSWER ______ are found in very low-density lipoproteins (VLDL). cholesterol - CORRECT ANSWER _______ is mainly found in low-density lipoproteins (LDL) high-density lipoproteins - CORRECT ANSWER _______ are a mixture of one-half protein and one-half phospholipids and cholesterol. lipid profile - CORRECT ANSWER A _______ can screen for increased risk of coronary artery disease. LDL - CORRECT ANSWER High levels of ______ are linked to an increase in coronary artery disease because they circulate cholesterol in the arteries. HDL - CORRECT ANSWER _____ play a protective role against coronary artery disease because they carry cholesterol to the liver to be metabolized. lipids - CORRECT ANSWER Controlling ______ is very important in reducing coronary artery disease. c-reactive protein - CORRECT ANSWER _______ is an acute phase protein that increases during inflammatory process. c-reaction protein - CORRECT ANSWER A highly sensitive _______ test can predict heart attack risk. homocysteine - CORRECT ANSWER Folic acid, vitamin B6 and vitamin B12 break down _______. Adequate dietary intake of green leafy vegetables and grains fortified with folic acid, as well as vitamin B, can help reduce these levels. (It is an amino acid in the blood that may damage the lining of arteries and promote blood clots.) cardiac biomarkers - CORRECT ANSWER Proteins and enzymes released into the blood by damaged cardiac cells are known as ______. These help identify whether a patient is having or has had a recent myocardial infarction. creatine kinase - CORRECT ANSWER _______ is an enzyme found in th ebrain, skeletal muscle and heart muscle. troponin I and troponin T - CORRECT ANSWER Cardiac muscle contains proteins called ________, which control the muscle fibers that contract or squeeze the heart muscle. They detect minor myocardial damage not detected by CK-MB to diagnose myocardial infarction. T, I - CORRECT ANSWER Troponin __ appears slightly earlier than troponin ___ and remains elevated longer after cardiac damage. myoglobin - CORRECT ANSWER ______ rises before CK-MB or troponin so it can detect a myocardial infarction earlier for prompt treatment. 1.6 to 2.6 - CORRECT ANSWER Normal magnesium level is _____ mg/dL magnesium - CORRECT ANSWER low levels of _____ in blood can cause cardiac arrhythmias, hypertension, and tachycardia. (Also controls the heartbeat and regulates blood pressure. Many things can contribute to low levels including diuretic therapy, digitalis, some antibiotics, diabetes mellitus and myocardial infarction) angiography - CORRECT ANSWER This test is used to assess blood clot formation, peripheral vascular disease, and test vessels for potential grafting use. right sided catheterization - CORRECT ANSWER In ______ a catheter with or without a fiber optic tip is inserted into the basilic or cephalic vein or the femoral vein and advanced into the vena cava. pulmonary artery wedge pressure - CORRECT ANSWER The catheter can be wedged momentarily in the artery by inflating the balloon at the tip of the catheter. This position provides the ______, which reflects pressures in the left side of the heart. central venous pressure, cardiac output - CORRECT ANSWER Other pressures obtained with the right sided cardiac catheterization are right atrial pressure, which reflects _____, pulmonary artery systolic and diastolic pressures, _______ and mixed venous oxygen saturation if a fiberoptic catheter is used. left side of the heart - CORRECT ANSWER The _____ can be directly assessed by inserting a catheter into the brachial or the femoral artery. coronary artery disease - CORRECT ANSWER ______ can be assessed with coronary angiography. cardiac catheterization - CORRECT ANSWER Complication of _______ can be allergic reaction, breaking of the catheter, hemorrhage, thrombus formation, emboli of air or blood, dysrhythmias, MI, cerebrovascular accident, and puncture of the heart chambers or lungs. arterial line - CORRECT ANSWER A catheter attached to be transducer and monitor, called an ______, can be inserted into the radial or femoral artery to measure continuous arterial blood pressure. vena cava - CORRECT ANSWER The right atrial pressure measurement obtained from the pulmonary artery catheter reflects the pressure in the ______. preload - CORRECT ANSWER pressure stretching the ventricle of the heart from fluid returned to the heart electrophysiological study - CORRECT ANSWER To study the heart's electrical system, one or more catheters with electrodes art inserted via the femoral vein into the right side of the heart. Two or three electrodes are inserted usually. The heart's electrical impulses are then recorded and pacing can also be done. This is called a(n) _____. 1 hour - CORRECT ANSWER Smoking causes vasoconstriction that can last up to _____ after the smoking of one cigarette. antiemolism devices - CORRECT ANSWER ______ improve arterial blood flow and venous return to prevent the formation of blood clots. They are used for patients with peripheral vascular disease, on bedrest or after surgery or trauma. 1 to 2 - CORRECT ANSWER The tops of the stockings should be _____ inches below the bottom of the kneecap. carotid endarterectomy - CORRECT ANSWER If an occulsion is significant, a _______, which removes the plaque on the lining of the blocked or diseased carotid artery, is performed, usually several weeks before having cardiac surgery. talk - CORRECT ANSWER It should be emphasized that patients are not able to _____ while the endotracheal tube is in place. heparin - CORRECT ANSWER _____ is absorbed and stored in organs and tissue and can be sporadically released hours after surgery. As a result, the patient may have excessive bleeding. lactated Ringer's - CORRECT ANSWER The risk of an air embolism is minimized by priming the pump with ______ solution. ventricles to atria when the ventricles contract - CORRECT ANSWER The mitral and tricuspid valves prevent backflow of blood from where? lines the chambers of the heart and prevents abnormal clotting - CORRECT ANSWER Describe the purpose of the endocardium of the heart? bring oxygenated blood to the myocardium - CORRECT ANSWER What is the function of the coronary arteries? medulla - CORRECT ANSWER Where in the nervous system is the cardiac center found? left-sided heart failure - CORRECT ANSWER The increase of resting blood pressure with age may contribute to which of the following? vasoconstriction and aldosterone secretion - CORRECT ANSWER angiotensin II increases what? tobacco use - CORRECT ANSWER What is a modifiable cardiovascular risk factor that should be noted during patient data collection? decreased arterial flow to the extremity - CORRECT ANSWER If it takes longer than 3 seconds for the color to return when assessing capillary refill, what does this indicate? gait or walking belt - CORRECT ANSWER What is an important safety intervention that should be used while assessing a patient for orthostatic hypotension? sacrum - CORRECT ANSWER In which area should the nurse assess a patient who is on bedrest for presence of edema? reduced cardiac workload - CORRECT ANSWER A high fiber diet for cardiac patients is recommended for what purpose? Warfarin Coumadin - CORRECT ANSWER A patient is scheduled for vascular surgery. The patient is taking digoxin (Lanoxin), furosemide (Laxis), potassium, warfarin (Coumadin) and famotidine (Pepcid). Which medication may be stopped by the physician several days before surgery? Aorta - CORRECT ANSWER The largest artery in the body; it conducts freshly oxygenated blood from the heart to the tissues. Vena cava - CORRECT ANSWER a large vein carrying deoxygenated blood into the heart Pulmonary Artery - CORRECT ANSWER artery carrying oxygen-poor blood from the heart to the lungs Pulmonary Vein - CORRECT ANSWER one of two pairs of vessels carrying oxygenated blood from the lungs to the left atrium of the heart Right ventricle - CORRECT ANSWER pumps oxygen poor blood to the lungs Right atrium - CORRECT ANSWER Receives deoxygenated blood from the body Left atrium - CORRECT ANSWER receives oxygenated blood from the lungs Left ventricle - CORRECT ANSWER Pumps oxygenated blood into the aorta Tricuspid valve - CORRECT ANSWER valve between the right atrium and the right ventricle Bicuspid (mitral) valve - CORRECT ANSWER between left atrium and left ventricle Septum - CORRECT ANSWER Divides the right and left chambers of the heart Myocardium - CORRECT ANSWER muscular, middle layer of the heart Epicardium - CORRECT ANSWER outermost layer of the heart Endocardium - CORRECT ANSWER Inner layer of the heart Papillary muscles - CORRECT ANSWER Enlarged muscles in ventricles that are attached to chordae tendinae. Chordae tendineae - CORRECT ANSWER thin bands of fibrous tissue that attach to the valves in the heart and prevent them from inverting Pulmonary semilunar valve - CORRECT ANSWER heart valve opening from the right ventricle to the pulmonary artery aortic semilunar valve - CORRECT ANSWER heart valve located between the left ventricle and the aorta The respiratory system - CORRECT ANSWER Is basically a tract, divided into upper and lower respiratory portion.The upper tract is above the thoracic cavity ,and the lower portion is within the thoracic cavity. Arterial system to the lungs is - CORRECT ANSWER Reverse to the venous system; oxygenated blood is carried in arteries and unoxygenated is carried in veins Pulmonary artery in respiratory system - CORRECT ANSWER Goes to the heart; vein carries oxygen from heart to body Respiratory system consists of - CORRECT ANSWER -nose and nasal cavity -pharynx -larynx -trachea and bronchial tree -lungs and pleural membranes Nares - CORRECT ANSWER opening through the nose carrying air into the nasal cavities Sinuses - CORRECT ANSWER Hollow cavities that have mucous membranes and help tighten the weight of the skill and have sound Alveoli of the lungs - CORRECT ANSWER The site of gas exchange between the air in the blood of pulmonary circulation; The rest of the system moves air into and out of the lungs. Cardiovascular system and the respiratory system - CORRECT ANSWER Supplies the body with oxygen and eliminates carbon dioxide. Nose - CORRECT ANSWER Mostly made of bone and cartilage covered with muscle and epithelium. Hairs inside the nostrils - CORRECT ANSWER Block the entry of dust and other particles Nasal cavities - CORRECT ANSWER Separated at midline by the nasal septum which is made of bone and cartilage Nasal mucosa - CORRECT ANSWER highly vascular, ciliated epithelium. moistens and warms inhaled air. Dust and microorganisms get trapped in the mucus produced by goblet cells and are swept back into the pharynx by the cilia. Protective mechanisms nasal hair in turbinates - CORRECT ANSWER Trap dust and microorganisms. Protective mechanism mucous membranes - CORRECT ANSWER Warm and moisten inhaled air; trap inhaled particles. Protective mechanisms cilia - CORRECT ANSWER Move particles toward pharynx to be swallowed or coughed out. Protective mechanism irritant receptors in nose and airways - CORRECT ANSWER Trigger sneeze and cough to remove foreign debris. Protective mechanism alveolar macrophages - CORRECT ANSWER Phagocytize foreign particles and bacteria. Paranasal sinus - CORRECT ANSWER Air cavities in the maxillary,frontal,sphenoid,and ethmoid bones that open into the nasal cavities, releasing mucus.; lessen the weight of the skill and provide resonance for the voice Pharynx - CORRECT ANSWER Posterior to the nasal and oral cavity . It has three regions: nasopharynx, oropharynx,and laryngopharynx. Nasopharynx - CORRECT ANSWER Extends from the posterior nares to the soft pallet. It contains openings to the right and left auditory( eustachian)tubes. Oropharynx - CORRECT ANSWER Space between the soft pallet and the base of the tongue. It contains the palatine tonsils (the ones most commonly removed by tonsillectomy )as well as the lingual tonsils ,found at the base of the tongue. Laryngopharynx - CORRECT ANSWER Passes dorsal to the larynx and connects to the esophagus. Soft palate and uvula - CORRECT ANSWER Rise to block the nasopharynx during swallowing Lingual tonsils, the adenoid (pharyngeal tonsil), and the palatine tonsils - CORRECT ANSWER Form a ring of lymphatic tissue around the pharynx and destroy pathogens that penetrate the mucosa Larynx - CORRECT ANSWER Airway between the pharynx and trachea. It houses the vocal chords and produces sound that can be formed into speech Epiglottis - CORRECT ANSWER At the top of the larynx prevents ingested materials from entering the trachea; closes over the top of the larynx during swallowing to direct food and liquids into the esophagus- is the uppermost cartilage The cartilaginous walls are line with - CORRECT ANSWER Ciliated epithelium Vagus and accessory cranial nerves - CORRECT ANSWER Innervate the larynx. Trachea - CORRECT ANSWER Descends from the larynx to the primary bronchi. Mucosa - CORRECT ANSWER Ciliated epithelium; mucus with trapped dust and microorganisms are swept up toward the pharynx and is swallowed. Bronchioles - CORRECT ANSWER Have no cartilage in the walls to maintain patency , therefore they can be closed completely by bronchoconstriction. Lungs - CORRECT ANSWER Occupy the thoracic cavity on each side of the heart, extending from the clavicles to the diaphragm, and are protected by the ribs(costae) On the medial(mediastinal) surface of each lung is - CORRECT ANSWER An indentation called the hilus, where the primary bronchus and the pulmonary vessels enter the lung What provides lubrication to To reduce friction during lung expansion - CORRECT ANSWER A thin layer of fluid between the visceral and parietal pleural membranes Both the alveoli and the surrounding alveolar capillaries are made of - CORRECT ANSWER Simple squamous epithelium; that is, their walls are only one cell in thickness to permit diffusion of gases e Each alveolus is lined with - CORRECT ANSWER A thin layer of tissue fluid that is essential for the diffusion of gases, but the surface tension of the fluid tends to make the walls of an alveolus stick together internally Surfactant - CORRECT ANSWER A lipoprotein that mixes with the tissue fluid and decreases surface tension to permit inflation; secreted by alveolar cells b Between clusters of alveoli is - CORRECT ANSWER Elastic connective tissue that can stretch during inhalation and recoil during exhalation; allows passive exhalation without the expenditure of energy Trachea purpose - CORRECT ANSWER A ridge tube about 4.5 in long and 1 in wide. C shaped rings of cartilage in encircle the trachea to reinforce it to keep it from collapsing during inhalation. The open part of the "C " faces posteriorly, given the esophagus room to expand during swallowing; lies in front of the esophagus Carina - CORRECT ANSWER The trachea extends from the larynx to the cartilaginous ridge; this then branches into two primary bronchi Primary bronchi - CORRECT ANSWER Supported by C-shaped rings of cartilage(consists of elastic connective tissue) Right bronchus - CORRECT ANSWER Slightly wider and more vertical than other, making this the most likely location for aspirated (inhaled) food particles and small objects to lodge.(consists of elastic connective tissue) Immediately after entering the lungs, the primary bronchi branch into - CORRECT ANSWER Secondary bronchi: one for each of the lungs lobes The left lung consists of how many lobes? - CORRECT ANSWER Two lobes; so has two secondary bronchi Secondary bronchi branch into - CORRECT ANSWER tertiary bronchi; the cartilaginous rings become irregular and disappear entirely in the smaller bronchioles t Tertiary bronchi continue to branch, resulting in very small airways called - CORRECT ANSWER Bronchioles Less than 1 mm wide and lacking any supportive cartilage - CORRECT ANSWER Bronchioles Bronchioles divide further to form thin walled passages called - CORRECT ANSWER Alveolar ducts Alveolar ducts throughout the lungs terminate in clusters of alveoli called - CORRECT ANSWER Alveolar sacs; the primary structures for gas exchange The right lung consists of how many lobes? - CORRECT ANSWER 3 lobes; so it has three bronchi Larynx is formed - CORRECT ANSWER by nine pieces of cartlidge to keep it from collapsing. A group of ligaments bind the pieces of cartilage together and to adjacent structures in the neck. Thyroid Cartlidge - CORRECT ANSWER The largest piece of cartilage also known as the Adams apple. Vestibular folds - CORRECT ANSWER Superior pair of the mucous membrane lining the larynx; Occasionally, false vocal cords- play no role in speech .they close the glottis opening between the vocal cords during swallowing to keep food and liquid out of airway. Vocal chords - CORRECT ANSWER Inferior pair ,produces sound when air passes over them. Glottis - CORRECT ANSWER Opening between the cords. Phrenic nerve - CORRECT ANSWER Carries out breathing-normal respiration rate 12 to 20 breath/min Bronchial tree - CORRECT ANSWER At the carina, the trachea branches of the two primary bronchi-primary bronchi bring to them to secondary bronchi -secondary bronchi break into smaller tertiary bronchi- tertiary bronchi branch into bronchioles -bronchioles divide into alveolar ducts. Alveolar sacs - CORRECT ANSWER Alveolar ducts throughout the lung terminate in clusters of grapes; the primary structure for gas exchange; have macrophages and phagocytosis (devour cells, debris, etc) Alveolar cells - CORRECT ANSWER Secrete pulmonary surfactant; mixes with body tissue and cells around it and decreases surface tension protective mechanisms of the respiratory system - CORRECT ANSWER -nasal hairs and turbinates -mucous membranes(help warm and humidity the air you breathe) -cilia -irritant receptors in the nose and airway -alveolar macrophages Transportation of gases - CORRECT ANSWER -hemoglobin -CO2 -chemical action exchanges these gases at the alveoli level Regulation of respiration (RR 12-20) - CORRECT ANSWER -nervous -chemical Affects on respiratory system from aging - CORRECT ANSWER -weak and atrophy respiratory muscles -reduces elastic recoil of lung tissue -deteriorating cilia -decreased cough reflex -reduces effectiveness of alveolar macrophages -reduced number of alveoli sacs; decreases gas exchange availability Diagnostic tests of respiratory system - CORRECT ANSWER Blood draws: complete blood count (CBC) Arterial blood gases(ABGs) D-Dimer (products let off by a clot) Sputum C/S -throat culture -nasal samples -oxygen saturation -capnography (used for co2 level checking; ventilated patients) -chest x-ray -computed tomography -ventilation-perfusion scan (lung scan) ;dye is injected into system -pulmonary function studies -pulmonary angiography- used to look for vessel disorder in lung impairing circulation (pulmonary embolism) -bronchoscopy - scope into site of lungs looking for cancer; throat is numbed with anesthetic spray and meds Nasal cannula rate - CORRECT ANSWER 2-6L/min Simple mask rate - CORRECT ANSWER 5-8 L/min Partial re-breathed rate - CORRECT ANSWER 6-10 L/min increased amount of O2 with lower O2 flow Non rebreather flow - CORRECT ANSWER 6-10 L/min; bag fills with O2 so breathe that in too Face tent rate - CORRECT ANSWER 8-10 L/min Trach collar use - CORRECT ANSWER For administration of humidity and warm O2 Venturi - CORRECT ANSWER Specific and precise amount of oxygen delivered Post complications for angiography - CORRECT ANSWER Open site at risk for bleeding, patient is NPO, kept on bed rest and flat for 3-8 hours, vital signs, dye needs to be flushed out of system Inspiration External intercostal - CORRECT ANSWER intercostal muscles pull the ribs upward and outward the widening the thoracic cavity Internal Intercostal - CORRECT ANSWER Help elevate the real Cyanosis - CORRECT ANSWER A bluish color .note the color of skin ,lips ,mucous membranes ,nail beds and clubbed nails . A late sign of oxygen deprivation Apnea - CORRECT ANSWER Absence of respirations Diaphragm - CORRECT ANSWER Contracts, flattens and drops, pressing the abdominal organs downward and enlarging the thoracic cavity. Expiration - CORRECT ANSWER Internal intercostal muscles pull the ribs downward as the external intercostals relax. The diaphragm relaxes bulging upward and pressing against the base of the lungs reducing the size of the thoracic cavity. Air is pushed out of the lungs. Cheyne-Stokes - CORRECT ANSWER Respirations that gradually become faster and deeper than normal, then slower; alternates with periods of apnea Primary respiratory muscles - CORRECT ANSWER Diaphragm, inferior to the lungs and the external intercostal muscles between the ribs Respiratory centers of the brain - CORRECT ANSWER Located in the medulla oblongata and pons, innervate muscles of respiration via the intercostal and phrenic nerves Inhalation/Inspiration - CORRECT ANSWER Occurs when motor impulses from the medullar cause contraction of the respiratory muscles; impulses travel along the Phrenic nerves and cause the dome-shaped diaphragm to contract and flatten inferiorly Intercostal nerves cause the - CORRECT ANSWER External intercostal muscles to expand the thoracic cavity in the ateroposterior dimension; these movements then expand the pleural membranes and therefore the lungs due to adhesion from serious fluid As the lungs expand - CORRECT ANSWER Alveolar pressure falls below atmospheric pressure, and air enters the nose and respiratory passages c compliance - CORRECT ANSWER Ease of thoracic and lung expansion Exhalation - CORRECT ANSWER A passive process; lungs are compressed as the thoracic cavity reduces volume and the recoil of the elastic lung tissue compresses the alveoli; alveolar pressure rises above atmospheric pressure, and air is forced out of the lungs Forced exhalation - CORRECT ANSWER An active process requiring contraction of the intercostal muscles compressing the thorax, and abdominal muscles that force the diaphragm superiorly, increasing compression of the lungs The base of each lung rests - CORRECT ANSWER On the diaphragm The right lung contains two fissures: - CORRECT ANSWER -horizontal fissure -oblique fissure Right lung - CORRECT ANSWER Is shorter, broader, and larger than the left it has three lobes the superior the middle and the inferior. (Contains two fissures horizontal fissures and oblique fissures) 55 - CORRECT ANSWER Right lung Handles _____% of gas exchange The use of the sternocleidomastoid muscles causes - CORRECT ANSWER The shoulders to rise during labored inspiration During forced expiration - CORRECT ANSWER The abdominal and intercostal muscles contract Kussmaul's - CORRECT ANSWER Faster and deeper restoration without pauses Bradypnea - CORRECT ANSWER Slow but regular respiration's Tachypnea - CORRECT ANSWER Increased respiratory rate Hyperventilation - CORRECT ANSWER Deeper respiration's; normal rate Barrel chest - CORRECT ANSWER Associated with trapped air in the lungs Eupnea - CORRECT ANSWER Normal respiratory rate and rhythm Respiratory excursion - CORRECT ANSWER Can also be palpated. This is a rough measurement of chest expansion on inspiration.; helpful if asymmetry or hypoventilation is suspected Top, or apex of each lung - CORRECT ANSWER Extends about 1/2" above the first rib Crepitus - CORRECT ANSWER Also called subcutaneous emphysema. Feels like Rice Krispies under the skin when felt with fingers. It occurs when air leaks into subcutaneous tissues because of pneumothorax or a leaking chest tube site. A normal chest sounds - CORRECT ANSWER Resonant and is the same bilaterally except over the heart Percussion - CORRECT ANSWER Typically done by then experienced nurse it involves tapping on the anterior and posterior chest, in each intercostal space and comparing sounds from side to side. Auscultation - CORRECT ANSWER Listening with stethoscope to the anterior, lateral, and posterior chest during an entire inspiration and expiration at each interspace; easiest if the patient is sitting, deep breathing through the mouth rest at intervals WBC Count normal values - CORRECT ANSWER 5000-10,000 cells/mm cubed venous blood Associated conditions: increase in infection RBC Count normal values - CORRECT ANSWER Male: 4.5-6.2 million cells/mm cubed venous blood Female: 4.2-5.4 million cells/mm cubed venous blood Associated conditions: increase in chronic lung disease, dehydration Decrease in anemia, hemorrhage, overhydration with intravenous fluids Hemoglobin normal values - CORRECT ANSWER Male: 13.5-18 g/dL Female: 12-16 g/dL increase in chronic lung disease, dehydration Decrease in anemia, hemorrhage, overhydration with intravenous fluids Adventitious - CORRECT ANSWER Abnormal extra sounds indicate a pathological condition Course crackles - CORRECT ANSWER Fluid in airways ,moist bubbling sounds heard on inspiration or expiration ,blowing wind : Disorder pulmonary edema, bronchitis, pneumonia Fine crackles rales - CORRECT ANSWER Alveoli popping open on inspiration- Velcro being torn apart, heard at end of inspiration- Disorder Heart failure, atelectasis Bound to iron and hemoglobin in the red blood cells - CORRECT ANSWER 98 and a 1/2% of oxygen is carried in the blood Wheezes - CORRECT ANSWER Narrowed airways, fine high pitched violins mostly on expiration- Disorder Asthma Base - CORRECT ANSWER Lungs rest on the diaphragm Left lung - CORRECT ANSWER Only has two lobes because the heart extends to this side of the body Contains one fissure: oblique fissure Percentage of carbon dioxide - CORRECT ANSWER 70% carried as a bicarbonate ion in the blood plasma. Stridor - CORRECT ANSWER Airway obstruction- loud crowing noise heard without stethoscope-Disorder obstruction from tumor or foreign body (croup) Pleural friction rub - CORRECT ANSWER Inflamed pleura rubbing together- sound of leather rubbing together; grating sound- Disorder pleurisy, lung cancer, pneumonia, pleural irritation Diminished - CORRECT ANSWER Decreased air movement-faint lung sounds-Disorder emphysema,hypoventilation, obesity, muscular chest wall Absent - CORRECT ANSWER No air movement-no sounds heard-Disorder pneumothorax, pneumectomy Diagnostic test for the respiratory system CBC - CORRECT ANSWER Measurment of the RBC's and hemoglobin can give information about the oxygen carrying capacity of the blood. Dyspnea - CORRECT ANSWER Shortness of breath can be caused by reduction in RBCs are hemoglobin. Subjective data collection for respiratory system Lower respiratory tract - CORRECT ANSWER Do you feel short of breath ? Do you have a cough,is it productive what is the sputum look like? have you experienced night sweats,chills,or fever. Do you feel confused,light headed,or restless? Have you had any chest surgeries? Low grade fever Rational: respiratory and cardiac problems result from shortness of breath. Respiratory irritation or excessive secretions from the cough. Yellow, tan, or green sputum may accompany and infection; blood in the sputum is usually serious; colors occur from pneumonia ,tuberculosis pulmonary embolism or cancer. Night sweats possibility of tuberculosis and low Po2 indicates reduction oxygen to the brain Subjective data collection for respiratory system exposures - CORRECT ANSWER Do you have allergies that cause respiratory symptoms?so do you take over-the-counter medication for the allergies that affect respiratory function or interact with prescribed medications: do you smoke how many packs per day and how many years because respiratory disorders are caused or aggravated by exposure to tobacco smoke. have you been exposed to environmental smoke? pollutants such as radon,asbestos , coal dust or chemicals can cause lung disease. Pulmonary embolism is suspected when - CORRECT ANSWER An area of the lungs is well ventilated but has no blood supply Sputum culture and sensitivity - CORRECT ANSWER Identifies pathogen's present in the sputum. The sensitivity test determine which anabiotic's will be effective against those pathogen's Steps for sputum collection - CORRECT ANSWER First obtain a sterile container. instruct the patient to take several deep breath and then cough sputum into the container sputum must come from the lungs. easier to obtain first thing in the morning after mouth care because secretions build up during the night; send specimen to lab immediately D-dimer - CORRECT ANSWER Blood test that measures fibrin degeneration products, which are present if there is a blood clot in the body. it helps to diagnose the presence of pulmonary embolism. PaO2 normal value - CORRECT ANSWER 75-100 mmHg Interpretation: increase in hyperventilation; decrease in Impaired respiratory function PaCO2 normal value - CORRECT ANSWER 35-45 mmHg Interpretation: increase in Impaired gas exchange Decrease in hyperventilation pH normal value - CORRECT ANSWER 7.35-7.45 Interpretation: increase in respiratory alkalosis with low PaCO2; decrease in respiratory acidosis with high PaCO2 Tidal Volume (TV) - CORRECT ANSWER Air inspired and expired in one breath Normal value: 400-600 mL at rest Residual Volume (RV) - CORRECT ANSWER Air remaining in lungs after maximum exhalation Normal value: 1000-1500 mL Functional residual capacity(FRC) - CORRECT ANSWER Air remaining in lungs after normal expiration Normal value: 2300 mL Inspiratory reserve - CORRECT ANSWER Amount of air beyond tidal volume that can be taken in with the deepest possible inhalation expiratory reserve - CORRECT ANSWER Amount of air beyond tidal volume in the most forceful exhalation Normal value: 1000-1500 mL Forced Vital Capacity (FVC) - CORRECT ANSWER Maximum amount of air expired forcefully after maximum inspiration Normal value: 3000-5000 mL Forced expiratory volume in 1 second (FEV1) - CORRECT ANSWER Amount of air expired in first second of forced exhalation, expressed as percent of FVC Normal value: 65%-85% of the FVC Peak Expiratory Flow Rate (PEFR) - CORRECT ANSWER Maximum flow of air expired during FVC (this is a rare rather than a volume ) Normal value: 450 L/ min HCO3 normal value - CORRECT ANSWER 22-26 mEq/L Interpretation: increase to buffer PaCO2 in acidosis; decrease to buffer PaCO2 in alkalosis Oxygen saturation normal value - CORRECT ANSWER 95-100% Interpretation: decrease in Impaired respiratory function Throat culture - CORRECT ANSWER Done to determine the presence of viral bacterial pathogens in the pharynx . use a swab to reach into the posterior pharynx behind the uvula without touching the patients mouth swab the red area or lesions. Use a tongue blade to hold tongue down while obtaining the culture. Warn the patient that a gag reflex may be triggered place the culture in a sterile tube with culture medium, according to pack. Send to lab asap Deep breathing should be repeated - CORRECT ANSWER Every 1-2 hours Sputum for AFB( acid fast bacillus) - CORRECT ANSWER When tuberculosis is suspected, which is caused by an acid-fast bacillus. Asked whether the patient should be placed in isolation while waiting for test results. Broad-spectrum anabiotic's covers until results identify issue Short huff - CORRECT ANSWER Helps clear larger airways Longer huff held out for several seconds - CORRECT ANSWER Helps open and clear smaller airways Oxygen saturation teat - CORRECT ANSWER Also called pulse oximetry,O2 sat, or Spo2. Noninvasive way to measure arterial oxygenation. 95% or greater considered normal. 90% or below requires oxygen and below 75% prepare for emergency intervention Using antigenic breathing techniques the patient is taught - CORRECT ANSWER Technique 3 phases first : unstick patient breathes out completely and then takes slow deep breaths and exhales fully several times, suppressing urge to cough. This loosens mucus in lower airways Next: Collect pt takes 10 to 20 slightly deep breathes, exhaling normally, still suppress cough. This helps mucus move up to middle airways. Last: Evacuate the patient takes 10 to 20 breaths and huff cough to move mucus up and out. During the unstick and collect phases, airflow should be high enough to produce a rattle if secretions are present Capnography - CORRECT ANSWER Process of measuring a person's exhaled carbon dioxide level. It provides a continuous measurement of patient's ventilation status. A special sensor is placed between the endotracheal tube and the ventilator to measure the exhaled carbon dioxide Diaphragmatic breathing - CORRECT ANSWER Used to relax and conserve energy; this organ is the major muscle of breathing Steps: 1. Place one hand on the abdomen and the other hand on the chest 2. Concentrate on pushing out the abdomen during inspiration and relaxing the abdomen on expiration. The chest should move very little Chest x-ray examination - CORRECT ANSWER Help diagnose a variety of pulmonary disorders Computed tomography - CORRECT ANSWER Scan can show cancers, pneumonia ,emphysema and more. A spiral CT scan can be useful for evaluating trauma or blood vessel abnormalities in the chest after a chest X-ray. Can see soft tissue 3-D scan Ventilation perfusion scan - CORRECT ANSWER Lung scan . A radioactive substance is injected intravenously ,and a scan is done view blood flow to the lungs(perfusion); another radioactive substance is inhaled and scanning shows how well oxygen is disturbed in the lungs (ventilation) Arterial blood gas - CORRECT ANSWER Arterial blood gases are measured to determine the effectiveness of gas exchange. The sample is usually taken from the radial artery in the wrist by a respiratory therapist our laboratory technician specially trying to do this. This can be painful and you want to apply pressure on the site for five minutes after the test to permit bleeding Pulmonary function studies - CORRECT ANSWER Series of test done to determine lung volume,capacity and flow rates. Commonly used to help diagnose and monitor restrictive or obstructive lung disease . patient asked to use a special mouthpiece to blow into a cylinder that is connected to a computer Pulmonary angiography - CORRECT ANSWER Involves an x-ray examination of the pulmonary vessels after IV administration of radiopaque dye. It is used to help diagnose pulmonary embolisms or other pulmonary vessel disorders. Bronchoscopy - CORRECT ANSWER Involves the use of a flexible endoscope to examine the larynx,trachea ,and bronchial tree. Can be used diagnostically for visilization or obtain a biopsy specimen for examination . can also be used therapeutically to remove an obstruction of foreign body,or thick secretions Nasal samples - CORRECT ANSWER Nasopharyngeal swab can be used to identify low or respiratory viruses. Swab nasal passages or pharynx or by using a small amount of saline to wash out the nose depending on type of test order Retraction of - CORRECT ANSWER The Chest wall between the ribs occurs when airways are obstructed and can indicate serious distress. Medulla oblongata and pons - CORRECT ANSWER Respiratory centers of the brain Alveoli are wrapped in what? - CORRECT ANSWER A fine mesh of capillaries t The extremely thin walls of the alveoli, and the closeness of the capillaries - CORRECT ANSWER Allow for efficient gas exchange The diaphragm during expiration - CORRECT ANSWER Relaxes, bulging upward and pressing against the base of the lungs, reducing the size of the thoracic cavity; air is then pushed out of the lungs Chest wall oscillation vest(vest therapy) - CORRECT ANSWER Inflatable vest is placed on the patient and a compressor generates pulses of air into the vest to vibrate the patients chest; helps loosen secretions so that they can be expectorated; patient must cough during and after the therapy for it to be effective Vibratory Positive Expiratory Pressure Device - CORRECT ANSWER Small handheld device where the patient blows into the mouthpiece and it makes a heavy steel ball inside bounce around in its chamber, which sends vibrations back into the airways to help loosen mucus; creates positive pressures which opens airways The exchange of air occurs through what's called the - CORRECT ANSWER Respiratory membrane Respiratory membrane consists of - CORRECT ANSWER The alveolar epithelium, the capillary endothelium and their joined basement membranes When fluid or air has collected in the pleural space this can indicate - CORRECT ANSWER A collapsed lung (pneumothorax) , pleural effusion, penetrating chest injury or during chest surgery Smoking cessation - CORRECT ANSWER Intervention behavior modification ,counseling ,set up a quit day ,nicotine replacement therapy ,drug therapy ,acupuncture ,hypnosis and physical activity Check and mark amount of drainage in collection chamber every - CORRECT ANSWER 8 hours and prn as ordered Oxyhemoglobin is formed - CORRECT ANSWER In the lungs, where the partial pressure of oxygen (PO2) is high Huff coughing - CORRECT ANSWER Patients with COPD have a weak cough and airways that collapse easily. Technique: patient should keep the glottis and mouth open, and use the abdominal muscles to create a series of forced expirations, moving air and mucus up the bronchial tree. Finally, the patient should take one more controlled inhalation and a final huff cough to expel the mucus In the tissues where Po2 is low - CORRECT ANSWER Hemoglobin releases much of its oxygen; the remaining oxygen is dissolved in the plasma Bicarbonate ions form - CORRECT ANSWER When carbon dioxide enters RBCs and is converted to carbonic acid (H2CO3), which ionizes into bicarbonate ions (HCO3) and hydrogen ions(H+) The bicarbonate ions leave the RBCs for - CORRECT ANSWER The plasma, and the remaining hydrogen ions are buffered by the hemoglobin in the RBCs when blood reaches the lungs - CORRECT ANSWER An area of lower partial pressure of carbon dioxide (PCo2), these reactions are reversed-carbon dioxide is reformed and diffuse into the alveoli to be exhaled Carbon dioxide is also transported as - CORRECT ANSWER Carbaminohemoglobin (23%) and dissolved in plasma (7%) Chemoreceptors (in the carotid and aortic bodies) - CORRECT ANSWER Monitor blood levels of oxygen, carbon dioxide and pH. The medullar responds by increasing respiration during hypoxemia, hypercapnia, and/or academia Reasons for a tracheostomy - CORRECT ANSWER -have had a cancerous larynx removed -patients with airway obstruction caused by trauma or tumor -patients who have difficult clearing secretions from the airway -patients who need prolonged mechanical ventilation Tracheostomy tube - CORRECT ANSWER Consists of three parts: an outer cannula, and inner cannula and an obturator Obturator - CORRECT ANSWER A curved guide that is used only during insertion of the tube; after insertion, it is immediately removed and kept at the bedside for emergency use if the tracheostomy tube is accidentally removed Which tube remains in place at all times and is secured by ties to prevent dislodging - CORRECT ANSWER Outer cannula Which tube is removed at intervals, usually every 8 hours as needed for cleaning - CORRECT ANSWER Inner cannula Autogenic drainage - CORRECT ANSWER A variation on deep breathing for patients with thick secretions that are difficult to raise. Examples cystic fibrosis or severe COPD. Is also gentler and less likely to cause declines in oxygen saturation or uncontrolled coughing than other methods. Patient is taught to sit upright and breathe in more deeply than usually, slowly through the nose, and then hold the breath for 2-4 seconds; when holding the breath, the patient should keep the glottis open to prevent airway collapse. Exhale is done As a quiet sigh as if trying to steam up a mirror Fenestrated tubes - CORRECT ANSWER Tubes with openings (fenestra) in the cannula to allow air to flow up into the larynx for speaking; plugging the opening of ruble while speaking is done to divert air through the fenestra Passy Muir Valve - CORRECT ANSWER Special valve that allows air into the tracheostomy tube, through the vocal cords and out the nose and mouth on expiration, allowing the patient to speak; use of the valve eliminates the need for the patient to use a finger over the opening to speak; tracheostomy tube must be small enough for air to flow around it or it must be fenestrated to allow air to flow up through the vocal cords; of cuffed the cuff must be completed deflated A patient with a tracheostomy tube in place due to laryngectomy surgery - CORRECT ANSWER Will not have vocal cords and the trachea will no longer connect to the nose and mouth; patient will not be able to plug the tube or use a valve to talk; plugging a laryngectomy tube would cause suffocation Besides regulating the amount of carbon dioxide in body fluids, the respiratory system is important in - CORRECT ANSWER The maintenance of acid-base balance, measure by blood pH The aging respiratory system weakened and atrophied respiratory muscles - CORRECT ANSWER leads to decreased force of cough : diagnosis increased risk of respiratory infection Purse lip breathing - CORRECT ANSWER Technique helps keep airways open doing exhalation promotes carbon dioxide at excretion. use any time patient feel short of breath Teach the patient 1. Inhale slowly through the nose to the count of two using diaphragmatic breathing 2. Exhale slowly through pursed lips to the count of four Endotracheal tubes have a - CORRECT ANSWER Cuff(a ballon like area around the tube) to help maintain proper placement and to prevent leakage of air around the tube Intubated patients are at risk of developing - CORRECT ANSWER Ventilator associated pneumonia (VAP) because normal respiratory defense mechanisms are bypassed Reduce elastic recoil of lung tissue - CORRECT ANSWER Decreased force a cough diagnosis increased risk for respiratory infection and air trapping diagnosis decreased gas exchange Decrease in the rate of efficiency of respiration persmits - CORRECT ANSWER Excess carbon dioxide to accumulate in the blood; the resulting accumulation of excess hydrogen ions lowers pH Volume and frequency alarms sound when - CORRECT ANSWER Tidal volume or number of breaths per min fall outside present parameters Positioning - CORRECT ANSWER For patients SOB they can not tolerate lying down. Use fowler's or semi fowler's position to keep abdominal contents from crowding the lungs. Some prefer to sit in chair while leaning forward and placing their elbows on their knees or an over bed table. Nasal cannula - CORRECT ANSWER Low flow device, most common used, oxygen deliver through a flexible catheter that has two short nasal prongs; oxygen can be delivered at 1 to 6 L/min Oxygen therapy - CORRECT ANSWER Is ordered by HCP The patient is unable to maintain oxygenation. Patients are typically placed on supplemental oxygen when oxygen saturation is less then 90% on room air Simple face mask - CORRECT ANSWER A rate of 5 to 10L/min can deliver oxygen concentration from 40% to 60% Cautions for patient with NIPPV - CORRECT ANSWER -skin irritation from the mask and gastric distention from swallowing air; apply an adhesive skin barrier to the areas that come in contact with the mask to prevent irritation; to prevent gastric distention, place patient in semiFowlers position; use of topical saline or a special humidifier on the machine can reduce nose and mouth dryness Partial rebreather mask - CORRECT ANSWER Uses a reservoir to capture some exhaled gas for rebreathering. Vents on the side of the mask allow room air to mix with oxygen. It can deliver oxygen concentration of 50% or greater Suctioning can cause - CORRECT ANSWER Hypoxia, canal stimulation with resulting bradycardia, and even cardiac arrest Signs that suctioning is needed - CORRECT ANSWER Crackles of wheezes with or without a stethoscope or a dropping oxygen saturation value Position for patient with tracheostomy - CORRECT ANSWER Head of bed elevated to 30-45 degrees Oral care with 0.12% chlorhexidine solution can significantly - CORRECT ANSWER Reduce the incidence of VAP(ventilator associated pneumonia) FIO2 - CORRECT ANSWER fraction of inspired oxygen Ventilator rate - CORRECT ANSWER Frequency of breaths per min Assist control mode (AC; also called continuous mechanical ventilation, or CMV) - CORRECT ANSWER Ventilator delivers a breath each time patient begins to inspire. If patient doesn't breath, the machine continues to deliver a preset number of breaths per min Synchronized Intermittent Mandatory Ventilation (SIMV) - CORRECT ANSWER Allows patient to breath independently but delivers a minimum number of ventilations per min as necessary. Synchronized to patients own respiratory pattern Pressure support (PS) - CORRECT ANSWER Provides positive pressure in inspiration and expiration to keep alveoli open in a spontaneously breathing patient positive end-expiratory pressure (PEEP) - CORRECT ANSWER Provides positive pressure on expiration to help keep small airways open Non rebreather mask - CORRECT ANSWER Has one or both sides closed to limit the mixing of room air with oxygen. The vents allow exhalation but remain closed on inhalation. The reservoir bag has a valve to store oxygen for inhalation but does not allow entry of exhaled air. It is used to deliver oxygen concentrations of 70% to 100% Venturi mask - CORRECT ANSWER Is used for the patient who requires precise percentages of oxygen, such as the the patient with chronic lung disease with CO2 retention.A combination of valves and specified flow rates determined oxygen concentration. Transtracheal cather - CORRECT ANSWER A small catheter is a small tube that is surgically placed through the base of the neck directly into the trachea to deliver oxygen; used for long term therapy; doesn't obstruct the nose or mouth and can easily be hidden Risk of oxygen therapy - CORRECT ANSWER Patients with COPD usually have chronically high PaCO2 levels suffer possible lung damage from high o2 concentration delivered more then 24 hrs. Dry cough, chest pain, numbness in the extremities, lethargy, or nausea. A Pao2 greater than 100mm Hg; should be maintained on no more than 1-2 L of oxygen per minute Nebulizer mist treatment - CORRECT ANSWER Nebulized mist treatment use a nebulizer to deliver medication directly in the lungs; reduces systemic side effects; ex: bronchodilator such as albuterol, mixed with normal saline solution and sometimes with supplemental oxygen; other meds include corticosteroids, mucolytics, and antibiotics; pt used a handheld reservoir with tubing and a mouthpiece to breathe in med; can be used when a pt with chronic pulmonary disease becomes acutely dyspneic Metered dose inhalers - CORRECT ANSWER are another way to administer topical medication directly to lungs, minimizing systemic side effects Meds include corticosteroids, bronchodilators, and mast cell inhibitors; use propellants to deliver meds Incentive spirometry - CORRECT ANSWER Encourage deep breathing in patient at risk for collapse lung tissue, commonly a condition called atelectasis. Patient instructed to use spirometer 10 times each hr they are awake Chest physiotherapy - CORRECT ANSWER Which include postural drainage,percussion, and vibration, helps move secretions from deep inside the lungs. It is indicated for the patient who has a weak or ineffective cough and is at risk for retaining secretions; used for patients with retained secretions due to conditions such as COPD, cystic fibrosis or bronchiectasis and patients on ventilators Thoracentesis - CORRECT ANSWER Involves the insertion of a needle into the pleural space. It is commonly done to aspirate fluid in patients with pleural effusion. May be performed to aspirate blood or air or to inject medication, determine the source of fluid or therapeutic to remove fluid and reduce respiratory distress. First verify that the patient understands procedure, obtain written consent, have patient void before procedure. Administer analgesic - put patient in sitting position, bending over a Bedside table or in a side lying position if unable to sit; as much as 2 L can be removed, sometimes more and the patient will usually report immediate reduction of dyspnea; after procedure apply a petroleum jelly dressing to prevent air leakage into the wound; assess vital signs every 15 mins times two, every 30 mins times two, then every 4 hours for 24 hours; pt is in bed rest for at least one hour after procedure Chest drainage - CORRECT ANSWER Involves insertion of one or two chest tubes by a physician into the pleural space to drain air or fluid. Tubes are connected to chest drainage system that collects the fluid and escaped air Stripping and milking - CORRECT ANSWER Stripping is done by holding the proximal end of the tubing and using the other hand to squeeze the tubing between two fingers while sliding the fingers toward the drainage system. It is now known that this process can create negative pressure at the openings in the tubing and can cause damage. Should only be done by HCP with specific instructions. Milking is done by gently squeezing portions of tubing from the patient to the system without a sliding motion. Somewhat more safe but still not done routinely consult with HCP for specific orders Chest drainage system - CORRECT ANSWER Continuous chest drainage involves insertion of one or two chest tubes by the physician into the pleural space to drain fluid or air. Water seal bottle or chamber - CORRECT ANSWER Each time patient exhales,air trapped in the pleural space travels through chest tube to the water seal bottle or chamber, under water, and then bubbles up and out of the bottle. The water acts as a seal,allowing air to escape from the pleural space but preventing air from getting back in during the negative pressure of inspiration. If constant bubbling occurs in water seal chamber, the system should be checked immediately for leaks. Suction bottle or chamber - CORRECT ANSWER Suction source is used to speed lung reinflation. A separate bottle with tubing attached to suction is used. The amount suction depends on level of water in bottle not the amount of suction set on the machine. Suction level ordered by physician and is almost always negative 20cm of water. There should be gentle bubbling not vigorous. Vigorous causes water evaporation which alters amount of suction. If it does evaporate more must be add to maintain correct suction. Chest tube insertion - CORRECT ANSWER By a physician inserts drainage tubes through the chest wall into pleural space either in surgery or at the bedside. If removal of air around a collapsed lung is the goal. inserted into the upper anterior chest, in the second to fourth intercostal space. If removal of fluid is the goal, insert tube in lower lateral chest, in eighth or ninth intercostal space. If patient has both air and fluid two tubes may be joined with a Y connector to lead to drainage system. Drainage bottle or chamber - CORRECT ANSWER Sometimes a third bottle is needed to catch fluid drainage from the pleural space. Sometimes small amount of drainage occurs because of insertion of chest tube. The drainage chamber is not emptied to measure drainage. Rather the drainage level in the bottle or chamber is marked and timed each shift to monitor the amount. Chart as input and output. If drainage increases or becomes bloody notify physician . If it fills up, either the chamber or the entire unit will need to be changed Tidaling - CORRECT ANSWER Water in the tube fluctuates up with each inspiration and down with each expiration, as much as 5 to10 cm Nursing care of patient with chest tube - CORRECT ANSWER Taped with adhesive tape. Apply petroleum jelly gauze and sterile occlusive dressing over the insertion site to prevent leakage. If the dressing soiled do not change: reinforce it with additional dressing, abd notify RN or physician. Some nurses may change chest tube dressing with special training. Obtain two padded clamps to keep at bedside never clamp for more then few seconds Removal of chest tube - CORRECT ANSWER Physician removes place petroleum jelly gauze and sterile occlusive dressing. Continue to watch for development of crepitus, monitor respiratory status and dressing. Aging respiratory system deteriorating cilia, decreased cough reflex, reduced effectiveness of alveolar macrophages - CORRECT ANSWER Diagnosis increased risk of respiratory infection Age and respiratory system reduced number of alveoli - CORRECT ANSWER Diagnosis Decreased gas exchange Subjective data collection for respiratory system upper respiratory tract - CORRECT ANSWER How often do you have headache or sinus tenderness ?Do you experience nosebleeds? Has your voice change? :Rationale may indicate sinusitis. Abnormality history predisposed future nosebleeds- voice change may indicate variety of disorders of nose and throat including cancer Subjective data collection for respiratory system treatments - CORRECT ANSWER Do you take any medication or use inhalers for respiratory problems do you have home oxygen or other home respiratory treatments Subjective data collection for respiratory system family history - CORRECT ANSWER Do you have any blood relatives with respiratory problems such as asthma emphysema or tuberculosis rational some respiratory disorders have a hereditary Tendency. tuberculosis is contagious Tracheotomy - CORRECT ANSWER A surgical opening through the base of base of the neck into the trachea. A tracheostomy when it is more permanent and has a tube inserted into the opening to maintain patency What's up - CORRECT ANSWER W -where it is, H -how does it feel?, A -Agggravating and alleviating factors? T -Timing S Severity U -Useful other data P -Patient perception Formula for smoking packs per year - CORRECT ANSWER If a patient has smoked two packs of cigarettes per day for 20 years he has a 40 pack for year smoking history that's 2 times the 20 years equals the 40 packs for year External intercostal muscles during inspiration - CORRECT ANSWER pull the ribs upward and outward, widening the thoracic cavity Internal intercostals during inspiration - CORRECT ANSWER Help elevate the ribs Boyle's Law - CORRECT ANSWER States that in a closed container of gases, volume and pressure are inversely related. Air moves on high- pressure low- pressure area Intubation risk - CORRECT ANSWER Developing ventilator associated pneumonia because normal respiratory defense mechanisms are bypassed. Frequent mouth care to reduce risk of aspirating oral microorganisms can help prevent VAP. Keep HOB elevated 30 to 45° at all times diaphragm during inspiration - CORRECT ANSWER Contracts, flattens, and drops, pressing the abdominal organs downward and enlarging the thoracic cavity; then air rushes in to equalize pressure Intubation - CORRECT ANSWER Patients are intubated with a special ET tube through the nose or mouth into the trachea. Usually a short-term intervention can damage vocal chords and surrounding tissues. Monitor ABG; used when patients are unable to breath effectively and to maintain adequate oxygenation because of airway obstruction of respiratory failure The internal intercostal muscles during expiration - CORRECT ANSWER Pulls the ribs downward as the external intercostals relax Nursing care for intubated patient - CORRECT ANSWER Asses regular patient's respiratory status abd tube placement. Auscultation lung sounds bilaterally to ensure that the tube has not been displaced into one bronchus. Monitor for skin irritation. May require soft wrist restraints for confused patients Ventilation - CORRECT ANSWER Is the term for the movement of air in and out of the alveoli Normal PH - CORRECT ANSWER 7.35-7.45 Mechanical ventilation - CORRECT ANSWER Are devices that provide ventilation (respirations) for patients who are unable to breathe effectively on their own. Ventilators use positive pressure to push oxygenated air via a cuffed ET or tracheotomy tube into the lungs at preset intervals.; may be needed after some surgeries , after cardiac or respiratory arrest, for declining arterial blood gases related to worsening respiratory disease, or for neuromuscular disease or injury that affects the muscles of respiration Ventilator mode/alarms - CORRECT ANSWER Low-pressure alarm sounds if the ventilator senses reduced pressure in the system(can be caused by disconnecting tubing, leaks in tubing or around the ET tube, or an under inflated cuff; may sound if patient has attempted to remove the tube High-pressure alarm sound for higher than normal resistant to airflow. Might occur if patient needs to be suctioned, coughing,biting on tube, or trying to talk, tubing kinked or obstructed; or if worsening respiratory disease causes decreased lung compliance; may also be triggered if the patient is anxious and unable to time his or her breaths with those of the ventilator; water in the tubing Respiratory acidosis - CORRECT ANSWER Any decrease in the rate are efficiency of respiration permits excess carbon dioxide to accumulate in the blood. The resulting accumulation of excess hydrogen ions lower pH. Noninvasive positive pressure ventilation - CORRECT ANSWER Alternative to intubation and mechanical ventilation for patients who are able to breathe on her own but are unable to maintain normal blood gases. Nursing care for mechanical ventilation - CORRECT ANSWER Important for healthcare team to be aware of any advanced directive. Keep the head of the bed at 45° angle to reduce risk of aspiration oral care with 0.12% chlorhexidine solution. Regular suctioning. Monitor for anxiety Noninvasive positive-pressure ventilation (NIPPV) - CORRECT ANSWER Alternative to intubation and mechanical ventilation for patients who are able to breath on their own but are unable to maintain normal blood gases. Patients with severe respiratory disease, sleep apnea, or neuromuscular diseases such as amyotrophic lateral sclerosis (ALS) that weaken respiratory muscles; External masklike device that fits over nose or mouth and nose . is successful in patients who are alert and able to cooperate, but do not have excessive secretions and able to breathe on their own for periods of time can be used with or without supplemental oxygen Two basic types of noninvasive positive pressure ventilation - CORRECT ANSWER Continuous positive airway pressure CPAP ( same amount of positive pressure is maintained throughout inspiration and expiration to prevent airway collapse) BIPAP a lower level of positive airway pressure is used on expiration. Respiratory system - CORRECT ANSWER Because of its role in regulating the amount of carbon dioxide in the body fluid ,it is important in the maintenance of acid- base balance measured by blood pH Patient teaching - CORRECT ANSWER Possible skin irritation,gastric detention from swallowing air,advise to place patient in semi fowler position. Topical saline humidifier to reduce nose and mouth dryness, air may leak around mask causing irritation to eyes just reposition mask monitor for anxiety Respiratory alkalosis - CORRECT ANSWER Occurs when the rate of respiration increases, eliminating exhaled carbon dioxide rapidly. Less carbon dioxide in the blood means fewer hydrogen ions are formed and the pH rises.; may occur during states of anxiety and hyperventilation , or when acclimating to a high altitude, before RBC production increases to provide sufficient oxygenation of tissue Metabolism acidosis - CORRECT ANSWER Occurs when the concentration of hydrogen ions in body fluids is above normal due to lowered HCO3-buffer. Common causes include kidney disease, uncontrolled diabetes mellitus, and severe diarrhea Respiratory compensation - CORRECT ANSWER Involves an increase in the rate and depth of respiration to exhale more carbon dioxide, which decreases hydrogen ion formation and raises the pH toward normal Metabolism alkalosis - CORRECT ANSWER Can be caused by over ingestion of antacid medication or by vomiting acidic gastric contents. The respiratory compensation involves a decrease in the breathing rate retain carbon dioxide in the body,increasing the formation of hydrogen ions, which lower the pH toward normal Respiratory compensation for an outgoing metabolic pH imbalance - CORRECT ANSWER Cannot be complete because the amount of carbon dioxide and that maybe exhaled are retained is limited; at most respiratory compensation is only about 75% effective Physical examination: Inspection - CORRECT ANSWER Start with the nose observing symmetry, swelling, or other abnormalities. Note whether patient has shortness of breath while speaking or moving. Assessment - CORRECT ANSWER Appraisal or evaluation of a patient's condition. Critical thinking - CORRECT ANSWER Use of knowledge and cognitive skills to make the best decisions possible in client care situations; increases the probability of a desirable outcome Data - CORRECT ANSWER A group of facts or statistics Evaluation - CORRECT ANSWER The judgment of anything. Evidence-based practice - CORRECT ANSWER When nursing care is based on good, welldesigned research studies. Nurses no longer massage a patients' reddening bony prominences to prevnt pressure ulcers. Through research, we now know that this practice should be avoided because it can further harm the damaged tissue. Intervention (actions) - CORRECT ANSWER One or more actions taken in order to modify an effect. Nursing diagnosis - CORRECT ANSWER Clinical judgment about an individual, family, or community in response to an actual or potential health problem or life processes Nursing process - CORRECT ANSWER An orderly, logical approach to administering nursing care so that the patient's needs for such care are met comprehensively and effectively. Objective data - CORRECT ANSWER FACTUAL DATA obtained through physical examination and diagnostic tests; objective data are observable or knowable through the five senses. Subjective data - CORRECT ANSWER Information that is given verbally by the patient; only the patient can feel and describe them(ex pain, headaches, out of breathe) Vigilance - CORRECT ANSWER Watchfulness: the condition of being watchful and alert, especially to danger; anticipating and preventing problems Why is critical thinking important in nursing? - CORRECT ANSWER Critical thinking involves reasoning, reflection, common sense, problem solving, analysis and inquiry. All these skills along with a nurse's knowledge will help make the best decisions possible in patient care situations. What attitudes and skills promote good critical thinking? - CORRECT ANSWER Intellectual Humility; Intellectual Courage; Intellectual Empathy; Intellectual Integrity; Intellectual Perseverance; Faith in Reason; and Intellectual Sense of Justice. What occurs in each step of the nursing process? - CORRECT ANSWER Gather data; Identify the problem; Decide what outcome is desirable; Plan what to do; Implement the plan of care; and Evaluate the plan of care. What are objective and subjective data? - CORRECT ANSWER OBJECTIVE DATA (aka: "signs") are pieces of factual information obtained through physical assessment and diagnostic tests that are observable through the five senses. Examples: 3-cm red lesion or respiratory rate 36/min SUBJECTIVE DATA are pieces of data provided verbally by the patient. It is documented normally in quotes (ex: "I feel out of breath" or "I have a headache") What is the best way to document objective and subjective data? - CORRECT ANSWER When recording OBJECTIVE data, include exactly what you observed and avoid any interpretation or vague meanings. (ex: "Capillary refill in 2-seconds." is better than "Capillary refill is good.") When recording SUBJECTIVE data use direct quotations as much as possible. Quotes accurately represent the patient's view and are least open to interpretation. How would you prioritize patient care based on Maslow's hierarchy of human needs? - CORRECT ANSWER According to Maslow, humans must meet their most basic needs first, then they can move up the hierarchy to meet higher level needs. Therefore, physiological needs are the most basic. For example: a person is short of breath cannot attend to higher level needs because the physiological need for oxygen is not being met. Once physiological needs are met, the patent can concentrate on meeting safety and security needs. Love, belonging, and selfesteem needs are nest: self-actualization needs are generally the last priority when planning care. Intellectual Humility - CORRECT ANSWER A nurse that does NOT "know it all" and is able to embrace to unknown and have the ability to say, "I'm not sure about that...I need more information."; not being overly cocky and being able to admit you are unsure how to do something and ask for help Intellectual Courage - CORRECT ANSWER Intellectual courage allows you to look at other points of view even when you do not agree with them at first. Able to admit you are wrong and able to listen to all sides/opinions towards something Intellectual Empathy - CORRECT ANSWER The ability to think, "If I were here in chronic pain such as this patient is, how would I feel" and respond appropriately; people may snap at you but you need to see their side of view and why they are upset which will have you watch how you respond to this situation Intellectual Integrity - CORRECT ANSWER Having the recognition of the need to be true to ones own thinking and to hold oneself to the same standards one expects others to meet Intellectual Perseverance - CORRECT ANSWER A nurse with intellectual perseverance does not give up. You notice side-effects of a new drug prescribed to a patient. The doctor says not to worry about it, but your concern continues. You do some research and share you proofs with you supervisor and pharmacist to discuss your concerns. Faith in Reason - CORRECT ANSWER you believe in yoru heart that good thinking, and reason, will result in the best outcomes for your patients. Intellectual Sense of Justice - CORRECT ANSWER Make sure the decisions you make are best for the patient and not for your, the nurse's needs. For example: a coworker would rather administer medications around his/her break schedule rather than the medication schedule. Maslow's Hierarchy of Human Need - CORRECT ANSWER WHATSUP: Guide to Symptom Assessment - CORRECT ANSWER W - Where it is? H - How does it feel? Describe the quality. A - Aggravating the alleviating factors. What makes it worse? What makes it better? T - Timing. When did it start? How long does it last? S - Severity. How bad is it? This can often be rated on a scale of 0 - 10 U - Useful other data. What other symptoms are present that might be related? P - Patient's perception of the problem. The patient often has an idea about what the problem is, or the cause, but may not believe that his or her thoughts are important to share unless specifically asked. In which of the following ways is critical thinking useful to the nursing process? a. It highlights the obvious solution to the problem? b. It can lead to a better outcome for the patient. c. It simplifies the process. d. It helps the nurse arrive at a solution more quickly. - CORRECT ANSWER b. It can lead to a better outcome for the patient. Critical thinking is use of cognitive skills or strategies that increase the probability of a desirable outcome. Which nurse is exhibiting intellectual humility? a. The nurse who is an expert at wounds care. b. The nurse who reports an error to the supervisor. c. The nurse who tries to empathize with the patient. d. The nurse who asks a coworker about a new procedure. - CORRECT ANSWER d. The nurse who asks a coworker about a new procedure. Asking a question shows humility. The nurse does not "know it all." Which of the following pieces of information is considered objective data? a. The patient's respiratory rate is 28,. b. The patient states, "I fell short of breath." c. The patient is short of breath. d. The patient is feeling panicky. - CORRECT ANSWER a. The patent's respiratory rate is 28. A respiratory rate of 28 is observable (measurable/fact). Selections b, c, and d are patient perceptions. An LPN is collecting data on a newly admitted patient who has an ulcerated area on his left hip. It is 2-inches in diameter and 1-inch deep, with yellow exudate. Which of the following statements best documents the findings in the patient's database? - CORRECT ANSWER d. Wound on left hip, 20inches in diameter, 1-inch deep, yellow exudate Selections a, b, and c all include the nurse's perceptions. A 34-year old mother of three children is admitted to a respiratory unity with pneumonia. Based on Maslow's hierarchy of needs, which of the following patient problems should the nurse address first? a. Frontal headache from stress of hospital admission. b. Anxiety related to concern about leving children. c. Shortness of breath from newly diagnosed pneumonia. d. efficient knowledge about treatment plan. - CORRECT ANSWER c. Shortness of breath from newly diagnosed pneumonia Shortness of breath is a physiological need and should be addressed first. When is a diagnosis considered medical? - CORRECT ANSWER When the health care provider directs most of the care When is a diagnosis considered nursing? - CORRECT ANSWER If the interventions needed to treat the problem are mainly independent nursing functions PES format (in nursing diagnosis) - CORRECT ANSWER Problem, etiology, signs and symptoms. Problem: from NANDA label (north american nursing diagnosis association) Etiology: starts with the phrase "related to..." Signs and symptoms: "as evidenced by" or "as manifested by." collaberative - CORRECT ANSWER The nurse, health care provider, and other members of the health team all work together to reach the desired outcome Fair-mindedness - CORRECT ANSWER To double check everything you do, make sure you are using clinical reasoning in treating your patients as well as everyone else clinical reasoning - CORRECT ANSWER Good thinking in nursing care; thinking through the various aspects of patient care to arrive at a reasonable decision regarding the prevention, diagnosis, or treatment of a clinical problem in a specific patient Define Nursing - CORRECT ANSWER the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations alleviation - CORRECT ANSWER Relief of suffering through the diagnosis and treatment of human response Advocacy - CORRECT ANSWER Support in the care of individuals, families, communities and population Interventions - CORRECT ANSWER The actions you take to help a patient meet a desired outcome Take treat and teach - CORRECT ANSWER Take- identify the data related to the problem that should be routinely collected Treat- great the problem by identifying deliberate actions to help reach the outcome Teach- teach the patient and family for the patient to learn to take care of themself physiological needs: maslows - CORRECT ANSWER those relating to the basic biological necessities of life: food, water, air, rest, exercise, elimination and shelter and sexual expression safety and security: maslow - CORRECT ANSWER person's need to be protected from actual or potential harm and to have freedom from fear; maintaining comfort, order, structure, physical safety, freedom from fear, protection Love and Belonging (Maslow) - CORRECT ANSWER understanding and acceptance of others in giving and receiving love; forgiving and receiving of affection, companionship, satisfactory interpersonal relationships and the identification with a group Self-esteem/ esteem of others: maslow - CORRECT ANSWER The individual seeks selfrespect and respect from others, works to achieve success and recognition in work, and desires prestige from accomplishments. self-actualization - CORRECT ANSWER The individual possesses feeling of self fulfillment and the realization of his/her highest potential The Large Intestine - CORRECT ANSWER Primary organ of bowel elimination Extends from the ileocecal valve to the anus The Large Intestine Functions - CORRECT ANSWER Completion of absorption Manufacture of some vitamins Formation of feces Expulsion of feces from the body Peristalsis is under control of the _________ system - CORRECT ANSWER nervous [system] Peristalsis Contractions occur - CORRECT ANSWER every 3 to 12 minutes Mass peristalsis sweeps occur - CORRECT ANSWER 1 to 4 times each 24-hour period Amount of food waste excreted in stool within 24 hours - CORRECT ANSWER One-third to one-half Variables Influencing Bowel Elimination (9) - CORRECT ANSWER Developmental considerations Daily patterns Food and fluid Activity and muscle tone Lifestyle, psychological variables Pathologic conditions Medications Diagnostic studies Surgery and anesthesia Developmental Considerations: Infants - CORRECT ANSWER —characteristics of stool and frequency depend on formula or breast feedings Developmental Considerations: Toddler - CORRECT ANSWER —physiologic maturity is first priority for bowel training Developmental Considerations: Child, adolescent, adult - CORRECT ANSWER —defecation patterns vary in quantity, frequency, and rhythmicity Developmental Considerations: Older adult - CORRECT ANSWER —constipation is often a chronic problem Foods Affecting Bowel Elimination: Constipating foods &Meds - CORRECT ANSWER — cheese, lean meat, eggs, pasta Meds: opioids, antacids w/ Al, iron sulfate, anticholinergic meds Foods Affecting Bowel Elimination: Foods with laxative effect - CORRECT ANSWER —fruits and vegetables (prunes), bran, chocolate, alcohol, coffee, & certain spicy foods Foods Affecting Bowel Elimination: Gas-producing foods - CORRECT ANSWER Gas-producing foods—onions, cabbage, beans, cauliflower Medications that promote peristalsis - CORRECT ANSWER Cathartics/ laxatives Medications that inhibit peristalsis - CORRECT ANSWER antidiarrheal Effect of Medications on Stool: Aspirin, anticoagulants - CORRECT ANSWER —pink to red to black stool can cause bleeding Upper GI bleed - CORRECT ANSWER Black Stool Lower GI Bleed - CORRECT ANSWER More Red Stool Effect of Medications on Stool: Iron salts - CORRECT ANSWER —black stool Effect of Medications on Stool: Antacids - CORRECT ANSWER —white discoloration or speckling in stool Effect of Medications on Stool: Antibiotics - CORRECT ANSWER —green-gray color - also at risk for HAI w/ C.Diff Physical Assessment of the Abdomen - CORRECT ANSWER Encourage Pt to void prior Inspection—observe contour, any masses, scars, or distention *Start in lower rt quad* Auscultation—listen for bowel sounds in all quadrants; start in lower right quadrant Note frequency and character, audible clicks, and flatus Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible 5-34 bowel sounds /minute Percussion—expect resonant sound or tympany Areas of increased dullness may be caused by fluid, a mass, or tumor Palpation—note any muscular resistance, tenderness, enlargement of organs, masses Physical Assessment of the Anus and Rectum - CORRECT ANSWER Inspection and palpation Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass Patient bear down; assess for internal hemorrhoids,fissures, fecal masses Inspect perineal area for skin irritation secondary to diarrhea Fissure - CORRECT ANSWER Narrow, slitlike opening; Linear break on the margin of the anus Stool Collection - CORRECT ANSWER Medical aseptic technique is imperative Wear disposable gloves Wash hands before and after glove use Do not contaminate outside of container with stool Obtain stool and package, label, and transport according to agency policy Patient Guidelines for Stool Collection - CORRECT ANSWER Void first so urine is not in stool sample Defecate into the container rather than toilet bowl Do not place toilet tissue in the bedpan or specimen container Notify nurse when specimen is available Endoscopy (Direct Visualization Study) - CORRECT ANSWER visual examination of a hollow body organ by use of an endoscope Visualizes abnormalities Locate source of bleeding provide biopsy of tissue samples Direct Visualization - CORRECT ANSWER -invasive, but no use of radiography: 1.Sigmoidoscopy 2.Cytoscopy 3.Endoscopy 4.Bronchoscopy Types of Direct Visualization Studies - CORRECT ANSWER Esophagogastroduodenoscopy Colonoscopy Sigmoidoscopy Wireless capsule endoscopy Esophagogastroduodenoscopy - CORRECT ANSWER Visual examination of the esophagus, stomach, and duodenum Endoscopic procedure that allows a visual exam of the upper GI tract Fasting 6-12 hours prior Local anesthetic sprayed into mouth/throat to depress gag reflex With hold food/drink until gag reflex returns Colonoscopy - CORRECT ANSWER visual examination of the large intestine from the anus to the ileocecal canal Sigmoidoscopy - CORRECT ANSWER Endoscopic exam Visual exam of sigmoid colon, rectum, and anal canal Wireless Capsule Endoscopy - CORRECT ANSWER Patient swallows camera containing capsule propelled through sm. intestine via peristalsis excreted 24-48 hours Pt NPO 10-12 hr prior Pt NPO first 2 hr after Pt consume sm meal after 4 hr Indirect Visualization - CORRECT ANSWER Done with Radiography/x-rays; Enhanced by radiopaque substances such as barium Indirect Visualization Studies - CORRECT ANSWER Upper gastrointestinal (UGI) & Small bowel series (xrays) Barium enema Abdominal Ultrasound Magnetic Resonance Imaging Abdominal CT Scan Barium Enema/Lower GI examination - CORRECT ANSWER contrast medium is injected into the rectum and x-rays are taken to search for lesions, inflammation, ulcers, tumors, strictures Stricture - CORRECT ANSWER a narrowing of a passage in the body Small Bowel Series/UGI - CORRECT ANSWER Pt drinks barium sulfate Barium coats esophagus, stomach, sm Intestine Abdominal Ultrasound - CORRECT ANSWER noninvasive test used to visualize internal organs by using very high frequency sound waves Visualizes all solid upper abdominal organs Magnetic Resonance Image - CORRECT ANSWER IV contrast may be given Abdominal CT scan - CORRECT ANSWER a series of cross sectional xray images that show abdominal organs Scheduling Diagnostic Tests - CORRECT ANSWER 1 — fecal occult blood test 2 — barium studies (should precede UGI) 3 — endoscopic examinations Noninvasive procedures take precedence over invasive procedures Occult Blood - CORRECT ANSWER Blood in the stool that is not visible to the eye. (PE Abdomen/GI) Patient outcomes for normal bowel elimination - CORRECT ANSWER Pt= soft, formed BM every 1-3 days w/o discomfort -relationship b/w bowel elimination, dietary fiber, fluid intake and exersize is explained -Pt will seek medical evaluatuon if changes in stool color/consistency persist Promoting Regular Bowel Habits - CORRECT ANSWER Timing- often an hour after meals Positioning if in bed do not raise HOB over 45 degrees Privacy Nutrition Exercise -Abdominal settings -Thigh strengthening Individuals at High Risk for Constipation - CORRECT ANSWER -Patients on bed rest taking constipating medicines(opiods/anticholinergics) Patients with reduced fluids or bulk in their diet Patients who are depressed Patients with central nervous system disease or local lesions that cause pain Nursing Measures for the Patient With Diarrhea - CORRECT ANSWER Answer bell calls immediately Remove the cause of diarrhea whenever possible (e.g., medication-normal w/i 1-3 days) If there is impaction, obtain physician order for rectal examination Give special care to the region around the anus After diarrhea stops, suggest the intake of fermented dairy products Preventing Food Poisoning - CORRECT ANSWER Never buy food with damaged packaging Never use raw eggs in any form Do not eat ground meat uncooked Never cut meat on a wooden surface Do not eat seafood that is raw or has a strong unpleasant odor Clean all vegetables and fruits before eating Refrigerate leftovers within 2 hours of eating them Give only pasteurized fruit juices to small children Methods of Emptying the Colon of Feces - CORRECT ANSWER Enemas Rectal suppositories Rectal catheters Digital removal of stool Oral lavage (bowel preps = GoLightly, magnesium citrate) Enema - CORRECT ANSWER An injection of fluid into the rectum to aid in the elimination of feces from the colon -fluid distends/irritates intestinal mucosa increasing peristalsis Types of Enemas - CORRECT ANSWER Cleansing Retention Medication Cleansing Enema - CORRECT ANSWER Stimulates peristalsis through distention and irritation of colon and rectum uses: Relieve constipation -Prevent involuntary escape of fecal material during surgical procedure -Promote visualizatio n of the intestinal tract -help establish reg. bowel function during bowel training program Solutions Used for Cleansing Enema - CORRECT ANSWER tap water 500-1000 ml normal saline 500-1000 ml soap solution 500-1000ml hypertonic solution- 70-130 mL -draw wtr into colon stimulating defecation reflex Large Volume Enema - CORRECT ANSWER Hypotonic solution (H2O) Isotonic Solution (normal saline) Rapid Colonic Emptying Adults 500-1000mL Infants 150-250mL dangerous for pt's with weakened Intestinal walls Small Volume Enema - CORRECT ANSWER Hypertonic Solution 70-130mL Draw wtr into colon -Contraindicated w/ sodium retention difficulties and renal impairment/reduced renal clearance Retention Enema - CORRECT ANSWER introduce solution into the colon to be retained for a prolonged period Retention Enemas: Oil-retention - CORRECT ANSWER —lubricate the stool and intestinal mucosa easing defecation 150-200 mL administered to adults administer at body temp Instruct pt to hold for 30 min Retention Enemas: Medicated - CORRECT ANSWER —provide medications absorbed through rectal mucosa (Fleet Enema) Retention Enemas: Carminative - CORRECT ANSWER —help expel flatus from rectum Magnesium Sulfate-glycerin-water[warm] (30mL,60mL,90mL) Retention Enemas: Anthelmintic - CORRECT ANSWER —destroy intestinal parasites Rectal Suppositories - CORRECT ANSWER conical/oval solid substance inserted into the rectum Oral Intestinal Lavage - CORRECT ANSWER "Bowel prep" before diagnostic test GoLYTELY/Colyte Bowel Training Programs - CORRECT ANSWER Manipulate factors within the patient's control -Food and fluid intake, exercise, time for defecation -Eliminate a soft, formed stool at regular intervals without laxatives When achieved, discontinue use of suppository if one was used Bowel Incontinence - CORRECT ANSWER Rectal tubes Fecal pouch Nasogastric Tube (Bowel use) - CORRECT ANSWER Inserted to decompress/drain stomach of fluid/unwanted stomach contents -Allows GI tract to rest before/after abdominal surgery to promote healing -Monitors GI bleeding Ostomy - CORRECT ANSWER Surgical opening Stoma - CORRECT ANSWER Part of the ostomy that is attached to the skin. Colostomy - CORRECT ANSWER Surgical procedure that provides an opening between the colon and the abdominal wall With new colostomy, Peristalsis returns - CORRECT ANSWER 2-5 days New Iliostomy drains when - CORRECT ANSWER 24-48 hours post liquid Types of Colostomies - CORRECT ANSWER Sigmoid colostomy Descending colostomy Transverse colostomy Ascending colostomy Ileostomy Sigmoid Colostomy - CORRECT ANSWER Left lower quadrant Fecal material is formed Stool is solid Descending Colostomy - CORRECT ANSWER Type of colostomy in which fecal material is semi-formed to formed Left Lower Quadrant Transverse Colostomy - CORRECT ANSWER Fecal material is semi formed 1. Most common 2. Stoma in upper, middle, or right 3. Soft stool 4. 4-6 months Ileostomy - CORRECT ANSWER allows liquid fecal content from ileum of sm intestine to be eliminated through stoma Ascending Colostomy - CORRECT ANSWER 1. Uncommon 2. Stoma on right 3. Stool is liquid to soft/continuous drainage) 4. Pouch worn at all times (4-6 months) Colostomy Care - CORRECT ANSWER -Keep patient as free of odors as possible; empty appliance frequently (no mare that half full) -Inspect the patient's stoma regularly *Note the size, which should stabilize within 6 to 8 weeks *Keep the skin around the stoma site clean and dry - Measure the patient's fluid intake and output -Explain each aspect of care to the patient and self-care role -Encourage patient to care for and look at ostomy Normal-Appearing Stoma - CORRECT ANSWER Should be dark pink to red and moist Pale stoma=anemia Purple blue stoma=compromised circulation/ischemia Bleeding around stoma should be minimal Size of stoma - CORRECT ANSWER protrude 1/2- 1 inch from abdominal surface initially= swollen/edematous stabilizes w/i 6-8 weeks Patient Teaching for Colostomies - CORRECT ANSWER -Explain reason for bowel diversion and rational for treatment -Community resources are available for assistance -Initially encourage patients to avoid foods high in fiber -Avoid foods that cause diarrhea or flatus -Drink two quarts of water daily -Teach about medications -Teach about odor control (intake of dark green vegetables) -Resume normal activity including work and sexual relations Changing a Colostomy Appliance (drainable) - CORRECT ANSWER emptied 1/3 full replaced every 3-7 days or when seal breaks away from skin use silicone based adhesive remover when removing Changing nondrainable colostomy pouch - CORRECT ANSWER remove/change 1/2 full use silicone based adhesive remover when removing Ileostomy care - CORRECT ANSWER output should be 500-1000ml/day paste-like substance empty bag with 1/4-1/2 full Comfort Measure - CORRECT ANSWER Encourage recommended diet and exercise Use meds only as needed apply ointments or astringents Use suppositories that contain anesthetics Diarrhea can be CAUSED BY these pathologic conditions: - CORRECT ANSWER Diverticulitis, infection, malabsorbption syndrome, tumors, diabetic neurapothy, hyperthiroidism, uremia Examples of causes of intestinal obstruction (pg 1351) - CORRECT ANSWER Mechanical obstructions: tumors, stenosis, adhesions, hernias & strictures Functional Obstructions: muscular dystrophy, DMII Parkinson's, Post-bowel surgery Diarrhea is a potential adverse effect of this drug: - CORRECT ANSWER amoxicillin clavulanate (Augmentin) [antibiotic]. but an anti-diarrheal is not suggested because it would prolong the exposure of the mucosa intestine to the irritating effects of the drug paralytic ileus - CORRECT ANSWER Temporary complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction. Lasts 24-48 hours food and fluids withheld during this time False positives for a Hema-test (occult blood) - CORRECT ANSWER Consuming red meat, animal liver & kidneys, salmon, tuna, mackerel, sardines, tomatoes, cauliflower, horseradish, turnips, melon, bananas, soybeans. >325mg salicylate daily, steroids, iron preparations *avoid these foods for 4 days prior ~no laxatives, enemas, suppositories 3 days prior, wait 3 days after menstruation* False Negative for a Hema-test (occult blood) - CORRECT ANSWER consumption of Vitamin C (even if bleeding is present) Foods that prevent odor (for ostomy) - CORRECT ANSWER buttermilk, cranberry juice, parsley, yogurt, dark green veggies Foods that prevent gas (for ostomy) - CORRECT ANSWER Crackers, toast, yogurts Daily Fiber Intake - CORRECT ANSWER 25-30 grams per day Fluid Intake - CORRECT ANSWER 64 oz 2000-3000 mL daily Mycobacterium tuberculosis - CORRECT ANSWER tuberculosis TB primarily affects - CORRECT ANSWER lungs Other areas of the body can be affected by TB such as - CORRECT ANSWER kidneys, liver, brain, and bone M. Tuberculosis can live in dark places in ________ for __________ - CORRECT ANSWER dried sputum/months Direct _____________ kills TB in a matter of hours - CORRECT ANSWER sunlight TB is spread by . . A) contaminated fomites B) food C) respiratory droplets D) vectors - CORRECT ANSWER C) respiratory droplets Latent TB infection - CORRECT ANSWER carries the disease but does not show symptoms and cannot infect others If immune system becomes compromised, in LTBI - CORRECT ANSWER some of the dormant bacteria will become active disease TB risk factors - CORRECT ANSWER Elderly poor health <5 years old close quarters inadequate ventilation HIV other TB risks include - CORRECT ANSWER AIDS chronic alcohol abuse cancer chemotherapy TB signs and symptoms - CORRECT ANSWER cough blood tinged sputum night sweats anorexia/weight loss low grade fever dyspnea, chest pain (late) hemoptysis - CORRECT ANSWER bloody sputum TB diagnostic tests - CORRECT ANSWER PPD skin test (Mantox) chest x-ray sputum cultures quatiFERON-TB gold IGRA - CORRECT ANSWER Interferon-gamma release assay (test for TB) TB: therapeutic interventions - CORRECT ANSWER Combination of drugs for 6-24 months: INH Rifampin Streptomycin Ethambutol Occasional surgical removal, isolation. TB prevention - CORRECT ANSWER 1.screening 2.quarantine 3.vaccination TB complications - CORRECT ANSWER pleurisy pericarditis peritonitis meningitis bone and joint infections genitourinary or GI infections infection of other body organs PPD (purified protein derivative) skin test - CORRECT ANSWER An alternate term for a TB skin test induration - CORRECT ANSWER positive PPD skin test local hard area on the skin Anergy panel - CORRECT ANSWER positive candida or mumps test means the immune system is intact, and the TB results are reliable Hepatitis - CORRECT ANSWER inflammation of the liver Types of Hepatitis - CORRECT ANSWER HAV HBV HCV HDV HEV Hepatitis A Virus (HAV) - CORRECT ANSWER Most common transmitted through the oral-fecal route Hepatitis B Virus (HBV) - CORRECT ANSWER Most prevalent in healthcare workers transmitted through any body fluid, including vaginal secretions, semen, and blood Hepatitis C Virus (HCV) - CORRECT ANSWER No vaccine/cure Blood transfusion <1990 Risky behavior Tattoos especially high Military due to overseas tattoos Hepatitis B vaccination - CORRECT ANSWER 96% effective household contact chronic liver disease same sex injection drug user health care worker dialysis patient Hepatitis A mode of transmission - CORRECT ANSWER Fecal to oral (enteric) route contamination of water Hepatitis incubation period - CORRECT ANSWER 3-7 weeks Hepatitis Complications - CORRECT ANSWER -Fulminant hepatitis Chronic infection risk of liver cancer Hepatitis symptoms include (prodromal) - CORRECT ANSWER fatigue anorexia malaise nausea jaundice pale stools amber or dark urine RUQ pain AIDS (acquired immune deficiency syndrome) - CORRECT ANSWER a life-threatening, sexually transmitted infection caused by the human immunodeficiency virus (HIV). AIDS depletes the immune system, leaving the person vulnerable to infections. Antiretroviral drugs - CORRECT ANSWER A specific term for antiviral drugs that work against retroviruses such as HIV AIDS portal of entry - CORRECT ANSWER Blood mucus membrane may take years to go from - CORRECT ANSWER HIV to AIDS AIDS latency period up to - CORRECT ANSWER 10 yrs AIDS symptoms - CORRECT ANSWER All/some ARC symptoms and: Oportunistic infections Headaches Blurred vision Dyspnea Dry cough Oral/skin lesions Dysphagia Dementia Seizures Focal neurological signs Deconditioning Anxiety and depression HIV-1 - CORRECT ANSWER the most prevalent and found around the world, incurable HIV-2 - CORRECT ANSWER retrovirus identified in 1986 in patients with AIDS in western Africa, incurable The window period - CORRECT ANSWER the time between exposure resulting in infection and the presence of detectable serum antibody clinical latency stage - CORRECT ANSWER -If HIV is untreated, the virus is slowly growing and also killing CD4 immune cells in the process. However, the host is usually asymptomatic at this stage -Latency starts after symptoms from acute stage go away and can last though the lifespan of the host AIDS prevention - CORRECT ANSWER *education *reducing risk behaviors *HIV screening *preventing mother-to-child transmission -preparedness Research-CDC, medical professional, Internet search Family and medical contact, respect for child clean classroom and awareness of weakness confidentiality treat as normal child Blood borne pathogens-gloves, biohazard disposal, washing hands AIDS-Preventing Precautions - CORRECT ANSWER -Stay sober -Avoid anal intercourse -Be selective in choosing partners -Use latex condoms -Never share needles -Don't become complacent about AIDS and STDs HIV modes of transmission - CORRECT ANSWER 1. Sexual Contact (with an exchange of body fluids) 2. Sharing needles or syringes (drugs, tattoos, piercings) 3. Birth (mother to child during pregnancy) HIV need a portal of entry such as - CORRECT ANSWER a tear in a mucous membrane or non intact skin access to the bloodstream lymphatic tissue Pre-exposure prophylaxis (PrEP) - CORRECT ANSWER pill containing antiviral drugs that is taken before exposure to HIV to prevent infection, recommended to high risk individuals [Show More]

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