ATI med surg. Questions and Approved Answers. Nursing 325 100%

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1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased ICP? a.... Flat jugular veins b. GCS score of 15 c. Sleepiness exhibited by the client d. Widening pulse pressure e. Decerebrate posturing 2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to cardioversion? a. Enoxaparin b. Metformin c. Diazepam d. Digoxin e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent blood clots that can be released into the client's circulatory system after cardioversion. This medication should not be withheld. f. Metformin g. Metformin might be withheld for a client scheduled for cardiac catheterization or other procedures involving contrast dye in order to prevent damage to the kidneys. However, metformin should not be withheld prior to cardioversion. h. Diazepam i. Sedatives are generally administered to clients prior to cardioversion to reduce anxiety and minimize the discomfort associated with the procedure. This medication should not be withheld. j. Digoxin: k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion. 3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority? a. Anorexia b. Abdominal pain radiating to the right shoulder c. Tachycardia d. Rebound abdominal tenderness i. Anorexia ii. Anorexia is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. iii. Abdominal pain radiating to the right shoulder iv. MY v. Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. vi. Tachycardia vii. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider. viii. Rebound abdominal tenderness ix. Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has acute cholecystitis. Therefore, there is another finding that is the nurse's priority. 4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following items at the client’s bedside? a. Suction machine b. Wire cutters c. Padded clamp d. Communication board e. Suction machine: The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration. f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary fixation to cut the wires in case the client vomits. This enables the client to clear their airway and reduce the risk for aspiration. g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to clamp the tube and prevent air from entering the client's chest if there is an interruption in the sealed drainage system. h. Communication board: The nurse should ensure a communication board is at the bedside of a client who has aphasia to assist the client with communicating. 5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s priority? a. Loosen the clothing around the client’s neck b. Check the client’s pupillary response c. Turn the client to the side. d. Move furniture away from the client i. Loosen the clothing around the client's neck: The nurse should loosen any restrictive clothing the client is wearing to prevent injury to the client. However, another action is the priority. ii. Check the client's pupillary response: The nurse should perform neurologic checks after the seizure to monitor the client's recovery. However, another action is the priority. iii. Turn the client to the side.: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration. iv. Move furniture away from the client.: AThe nurse should move furniture away from the client to prevent self-injury. However, another action is the priority. 6. A nurse is providing teaching to aclient who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? a. Ginkgo biloba b. Glucosamine c. Calcium d. Vitamin C i. Ginkgo biloba ii. Ginkgo biloba reduces the pain associated with peripheral vascular disease by promoting vasodilation. It can interact with medications that have anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine. iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing inflammation and stimulating the body's production of synovial fluid and cartilage. It can interact with medications that have antiplatelet or anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine. iv. Calcium:NSWER v. Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration. vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false negative in fecal occult blood tests, but it is not known to interfere with the absorption of levothyroxine. 7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure injury. Which of the following actions should the nurse take? a. Apply a wet-to-dry gauze dressing b. Irrigate with hydrogen peroxide solution c. Use a 30-ml syringe d. Attach a 24-gauge angiocatheter to the syringe. 8. a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry dressings to clean, granulating wounds as they interrupt viable, healing tissues when they are removed. Appropriate dressings for a wound that is developing granulation tissue include a hydrocolloid dressing and a transparent film dressing. b. Irrigate with hydrogen peroxide solution: the nurse should use hydrogen peroxide to clean contaminated surfaces. Hydrogen peroxide should not be used on a pressure injury wound because it destroys newly granulated tissue. Instead, the nurse should use solutions specifically designed as wound cleansers or 0.9% sodium chloride irrigation to irrigate the wound. c. Use a 30-mL syringe: NSWERThe nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi. d. Attach a 24-gauge angiocatheter to the syringe:the nurse should use an 18- or 19-gauge catheter that will apply the appropriate irrigation pressure. A 24-gauge angiocatheter delivers solutions at a higher pressure than necessary for irrigation and a can potentially damage the developing granulation tissues. 1. a nurse Is assessing a client who has Graves’ disease. Thich of the collowing images should undicate to the nurse that the client has exophthalmos: o o This image depicts entropion, which occurs when the skin of the eyelids turns inward, causing the eyelids to rub the eye. Entropion is caused by spasms of the eyelid muscle or trauma and occurs most often in older adult clients due to the loss of supportive tissue. o o This image depicts ectropion, which occurs when the skin of the eyelids turns outward, causing sagging of the lower lids due to muscle weakness. Ectropion occurs with aging and can cause drying of the cornea and ulceration. o o This image depicts ptosis, which occurs when excess skin of the upper eyelid drops down over the eye. Ptosis can occur due to aging or at any age due to diabetes, myasthenia gravis, or stroke. o o MY o The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve. 11. the nurse is providing teaching to a female client who has a history of UTI’s. which of the following information should the nurse include in the teaching? a. Avoid foods that are high in ascorbic acid b. Add oatmeal to the water when taking a tub bath c. Urinate every 6 hours d. Take daily cranberry supplements? 12. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which off the following statements should the nurse identify as an indication that the client understands the teaching? a. “ I will wash the ink markings off the radiation area after each treatment.” b. “I will use my hands rather than a washcloth to clean the radiation area.” c. “I will be able to be out in the sun 1 month after my radiation treatments are over.” d. “I will use a heating pad on my neck it if becomes sore during the radiation therapy.” i. "I will wash the ink markings off the radiation area after each treatment." ii. The ink markings designate the exact radiation area. The client should not remove these markings until they complete the entire radiation treatment. iii. "I will use my hands rather than a washcloth to clean the radiation area." iv. MY v. The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. vi. "I will be able to be out in the sun 1 month after my radiation treatments are over." vii. Radiation therapy causes skin to become sensitive to the effects of sun exposure and increases the risk for developing skin cancer. The client should avoid direct sunlight during the radiation treatments and for at least 1 year following the conclusion of the therapy. viii. "I will use a heating pad on my neck if it becomes sore during the radiation therapy." ix. The client should avoid exposing the treatment area to heat as this can cause further irritation to the skin. 13. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority? a. Initiate oxygen at 2 L via nasal cannula b. Apply firm pressure to the insertion site c. Take the client’s vital signs d. Obtain a stat order for an aPTT i. Initiate oxygen at 2 L/min via nasal cannula.: The nurse can apply oxygen to promote adequate tissue oxygenation. However, another intervention is the priority. ii. Apply firm pressure to the insertion site.: MY The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding. iii. Take the client's vital signs.: The nurse should take the client's vital signs to further determine the client's status. However, another intervention is the priority. iv. Obtain a stat order for an aPTT.: The nurse can request laboratory data to provide information about the client's coagulation status. However, another intervention is the priority. 14. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? a. Obtain ABGs b. Administer propofol to the client c. Instruct the client to allow the machine to breathe for them d. Disconnect the machine and manually ventilate the client. i. Obtain ABGs. The nurse should monitor ABG results to determine the effectiveness of mechanical ventilation, but this is not the first action the nurse should take. ii. Administer propofol to the client.: The nurse might need to administer propofol to provide sedation and increase the client's tolerance of mechanical ventilation, but this is not the first action the nurse should take. iii. Instruct the client to allow the machine to breathe for them.: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator." iv. Disconnect the machine and manually ventilate the client.: Many factors can cause a high-pressure alarm to sound. The nurse might have to disconnect the machine and manually ventilate the client if the ventilator fails or the client experiences respiratory distress, but this is not the first action the nurse should take. 15. A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? a. Decreased prothrombin time b. Elevated bilirubin level c. Decreased ammonia level d. Elevated albumin level i. Decreased prothrombin time: liver disease and severe liver cell damage causes the liver cells to produce less prothrombin, which prolongs prothrombin time. ii. Elevated bilirubin level: Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice. iii. Decreased ammonia level: The liver converts ammonia to urea. When this process is interrupted, as it is with liver disease or liver failure, ammonia levels rise. iv. Elevated albumin level: Albumin forms in the liver. When liver function is impaired, as it is with cirrhosis, albumin levels decrease. 16. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. “ I should avoid walking as much as possible.” b. “I should sit down and read for several hours a day” c. “I will wear clean graduatied compression stockings every day.” d. “I will keep my legs level with my body when I sleep at night.” i. "I should avoid walking as much as possible.": A client who has venous insufficiency should maintain an exercise regimen, such as routine walking, to decrease venous stasis. ii. "I should sit down and read for several hours a day.": A client who has venous insufficiency should avoid sitting or standing for prolonged periods of time due to the risk of developing deep-vein thrombosis or skin breakdown. iii. "I will wear clean graduated compression stockings every day.": Y The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand. iv. "I will keep my legs level with my body when I sleep at night.": A client who has venous insufficiency should elevate the legs above heart level while in bed to facilitate venous return and avoid venous stasis. 17. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? a. Potassium 4 mEq/L b. WBC count 10,000/mm3 c. Hct 45% d. Hgb 8 g/dL i. Potassium 4 mEq/L: A potassium level of 4 mEq/L is within the expected reference range. ii. WBC count 10,000/mm3: A WBC count of 10,000/mm3 is within the expected reference range. iii. Hct 45%: An Hct level of 45% is within the expected reference range. iv. Hgb 8 g/dL: Y The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia. 18. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed would healing? a. WBC count 6K b. BMI 24 c. Urine output 25ml/hr d. Albumin 4 WBC count 6,000/mm3: WBCs fight infection and respond to foreign bodies. Increased amounts are seen in clients who have an infectious process, and decreased amounts are seen in clients who are immunocompromised. A WBC count of 6,000/mm3 is within the expected reference range. BMI 24: BMI readings provide a means of determining a client's nutritional status. Clients who have a BMI less than 18.5 are considered at risk for complications, such as poor wound healing. Urine output 25 mL/hr: Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing. Albumin 4 g/dL: Albumin reflects nutritional status. A low level can indicate malnutrition, which would impair wound healing. An albumin level of 4 g/dL is within the expected reference range and indicates adequate nutritional status. i. 19. A nurse is caring for a client who is undergoing hemodialysis to treat ESKD. The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? i. Epoetin alfa: A client who has ESKD is at risk for anemia manifested by malaise, fatigue, and activity intolerance. The nurse should plan to administer an erythrocyte-stimulating agent, such as epoetin alfa, to a client who has anemia. ii. Furosemide: A client who has ESKD can develop pulmonary edema manifested by restlessness, shortness of breath, crackles, and blood-tinged sputum. The nurse should plan to administer a loop diuretic, such as furosemide, to a client who has pulmonary edema. iii. Captopril: A client who has ESKD often is hypertensive, which can further damage renal function. The nurse should plan to administer an antihypertensive medication, such as captopril, to a client who is hypertensive. iv. Calcium carbonate: ANSHypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement. 22. a nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care? a. Collect and place the client’s urine or feces in a biohazard bag b. Limit the client’s ambulation to their own room c. Wear a lead apron while providing care to the client d. Limit each visitor to 1 hr per day. i. Collect and place the client's urine or feces in a biohazard bag. ii. With sealed implants, the client's excretions are not radioactive. Standard precautions require gloves when handling body fluids or waste, but there are no special precautions required for this client's excreta. iii. Limit the client's ambulation to their own room. iv. Not only does the client require bedrest in a private room while the radiation implant is in place, but the nurse must also discourage the client from any excessive movements while in bed to prevent dislodging the implant. v. Wear a lead apron while providing care to the client. vi. MY vii. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure. viii. Limit each visitor to 1 hr per day.: The nurse should limit each of the client's visitors to 30 min per day and instruct them to remain at least 1.8 m (6 ft) from the client at all times. 23. A nurse is preparing to administer a unit of PRBCs to a client. Which of the following actions should the nurse take? i. Remain with the client for the first 15 min of the infusion.: Y ii. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood. iii. Prime the blood administration IV tubing with lactated Ringer's solution. iv. The nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or hemolysis of the RBCs. v. Verify the client's identity by using the client's room number prior to starting the transfusion. vi. The client's room number is not an acceptable client identifier. The nurse should ensure that the name and number on the client's identification band matches the name and identification number on the blood label. The client's identification, the blood compatibility, and the expiration date of the blood should be verified by two nurses. vii. Infuse the unit of packed RBCs within 8 hr.: The nurse should transfuse the packed RBCs within 2 to 4 hr based upon the client's age and cardiovascular status. Longer infusion times increase the risk for bacterial contamination of the blood product. 26. a nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client’s chart, which of the following findings should the nurse report to the provider? a. Potassium 4.1 mEq/L : The client's potassium level of 4.1 mEq/L is within the expected reference range. b. Heart rate 55/min: The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider. c. SaO2 92%: Y The nurse should ensure that the client's SaO2 level remains at or above 90%. This finding is within the expected reference range. d. Weight 67.1 kg (148 lb): The nurse should report a client's weight gain of 1.4 kg (3 lb) in a day or 2.3 kg (5 lb) or more in a week. 27.A nurse is caring for a client who has a potassium level of 3 mEq/L/ Whichh of the following assessment findings should the nurse expect? a. Positive trousseaus sign b. 4+ deep tendon reflexes c. Deep respirations d. Hypoactive bowel sounds i. Positive Trousseau's sign: positive Trousseau's sign indicates altered calcium levels. ii. 4+ deep tendon reflexes: Deep tendon reflexes are used to monitor magnesium levels. iii. Deep respirations: Shallow respirations occur with hypokalemia due to respiratory muscle weakness. iv. hypoactive bowel sounds: Y Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis. 28. A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse shouldinstruct the client to include which of the following foods that has the greatest amount of calcium in her diet. i. 12 almonds: Y The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia. ii. One small banana: The nurse should recommend a different food because there is another choice that contains more calcium. One small banana contains 5 mg of calcium. iii. 1 tbsp peanut butter: The nurse should recommend a different food because there is another choice that contains more calcium. One tbsp of peanut butter contains 8 mg of calcium. iv. 1/2 cup tomato juice: The nurse should recommend a different food because there is another choice that contains more calcium. A half cup of tomato juice contains 12 mg of calcium. v. 29.A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? a. Shellfish b. Aged cheese: Aged cheese 30.MY i. Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches. b. Peppermint candy c. Enriched pasta 31. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing FVD? a. HR 110/min b. BP 138/90 c. Urine Specific Gravity 1.020 d. BUN 15 mg/dL i. Heart rate 110/min client who has a 3- day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate. ii. Blood pressure 138/90 mm Hg: A blood pressure of 138/90 mm Hg is within the expected reference range. A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and hypotension. iii. Urine specific gravity 1.020: A urine specific gravity of 1.020 is within the expected reference range. A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit, which is indicated by a urine specific gravity greater than 1.030. iv. BUN 15 mg/dL: A BUN of 15 mg/dL is within the expected reference range. A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and a BUN greater than 20 mg/dL. 32.A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates and understanding of the teaching? a. “I will monitor my blood sugar carefully because the medication increases the secretion of insulin.” b. I should take the medication with a meal c. I can expect to gain weight while taking this medication d. While taking this medication, I will experience flushing of my skin.” i. "I will monitor my blood sugar carefully because the medication increases the secretion of insulin." ii. Metformin decreases the amount of glucose produced in the liver and increases tissue sensitivity to insulin. iii. "I should take this medication with a meal." iv. MY v. The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress. vi. "I can expect to gain weight while taking this medication." vii. Typically, clients lose weight when beginning to take metformin due to nausea and vomiting. viii. "While taking this medication, I will experience flushing of my skin." ix. Flushing of the skin is not an adverse effect of metformin. x. 33. A nurse is caring for a client who has anorexia, low grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? i. Obtain a sputum sample. ii. The nurse should obtain a sputum sample to identify the micro-organisms that are causing the client's illness. However, there is another action that the nurse should take first. iii. Administer antipyretics. iv. The nurse should administer antipyretics to treat the client's fever. However, there is another action that the nurse should take first. v. Provide hand hygiene education. vi. The nurse should provide hand hygiene education. However, there is another action that the nurse should take first. vii. Initiate airborne precautions. viii. MY ix. This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions. 1. 34.A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? a. The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude into the scrotum in men. b. 35. A nurse is performing a cardiac assessment for a client who has a MIM 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? a. Obtain a 12-lead ECG for the client. The nurse should obtain a 12-lead ECG to view the electrical activity of the heart. However, there is another action that the nurse should take first. b. Request to obtain the client's cardiac enzymes:The nurse should request cardiac enzymes to assess the client's cardiovascular status. However, there is another action that the nurse should take first. c. Check the client's blood pressure manually.: The nurse should check the client's blood pressure manually to obtain a baseline. However, there is another action that the nurse should take first. d. Listen with the client on their left side.: When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly. 36. A nurse is caring for a client who as ALS and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority? a. Temp 38.4 C b. Increased respiratory secretion c. Fluid intake of 200ml in the prior 8 hr d. Limited range of motion i. Temperature 38.4º C (101.1º F) ii. A temperature of 38.4º C can indicate an infection, but it is not the priority finding. iii. Increased respiratory secretions iv. MY v. Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia. vi. Fluid intake of 200 mL in the prior 8 hr vii. Fluid intake of 200 mL in the past 8 hr can indicate a risk for dehydration, but it is not the priority finding. viii. Limited range of motion ix. Limited range of motion can indicate a risk for impaired skin integrity, but it is not the priority finding. x. 37. A nurse is conduction and admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify which of the following findings requires further assessment? a. Hx of asthma b. Appendectomy 1 year ago c. Penicillin allergy d. TKA 6 months ago i. History of asthma 38.A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate. i. Appendectomy 1 year ago: A history of an appendectomy does not have an effect on a CT scan. However, clients who have a history of diabetes mellitus, renal impairment, or heart failure have an increased risk for renal failure when contrast media is used and require further screening. ii. Penicillin allergy: A penicillin allergy does not have an effect on a CT scan. However, a client who is taking certain medications, such as aminoglycosides, NSAIDs, and the biguanide metformin, is at increased risk for renal damage and requires further screening. iii. Total knee arthroplasty 6 months ago: A total knee arthroplasty does not have an effect on a CT scan. 39. A nurse is providing discharge instruction to a client who has a partial thickness burn on the hand. Which of the following instructions should the nurse include? a. Change the dressing every 72 hr b. Immobilize the hand with a pressure dressing c. Take pain medication 30 minutes after changing the dressing d. Wrap fingers with individual dressings 40. Change the dressing every 72 hr. 41.The nurse should instruct the client to change the dressing every 12 to 24 hr to allow for wound inspection. The client should observe the wound closely for manifestations of increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection. i. Immobilize the hand with a pressure dressing. ii. MY iii. A client who undergoes surgery to receive skin grafts for full-thickness burns should elevate and immobilize the graft site with cotton pressure dressings for 3 to 5 days following the procedure. This action prevents the graft from dislodging and allows for revascularization of the wound. iv. Take pain medication 30 min after changing the dressing. v. The nurse should instruct the client to take pain medication 30 min before a dressing change to decrease the level of pain during the procedure. vi. Wrap fingers with individual dressings. vii. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand. 42. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? a. Obtain a prescription for ABGs b. Administer IV Abx to the client c. Instruct the client to use the incentive spirometer d. Place the client in high fowler’s position. 1. Obtain a prescription for ABGs. 2. The nurse should obtain a prescription for ABGs to monitor the client's oxygenation status and determine the need for supplemental oxygen; however, another action is the priority. 3. Administer IV antibiotics to the client. 4. The nurse should administer IV antibiotics to treat the type of pneumonia the client has acquired; however, another action is the priority. 5. Instruct the client to use the incentive spirometer. 6. The nurse should instruct the client to use the incentive spirometer to improve their oxygen status and expansion of the lungs; however, another action is the priority. 7. Place the client in high-Fowler's position. 8. MY 9. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange. ii. 43. A nurse is providing teaching for a female client who has recurrent UTI’s/ which of the following information should the nurse include in the teaching? a. Take tub baths daily b. Drink at least 1 L of fluid daily c. Wear underwear made of nylon d. Void before and after intercourse i. Take tub baths daily. ii. The client should take showers instead of tub baths to prevent bacteria present in bath water from entering the urethra. iii. Drink at least 1 L of fluid daily. iv. The client should drink 2 to 3 L of fluid daily to keep her urine dilute and to flush bacteria out of the urinary tract. v. Wear underwear made of nylon. vi. The nurse should encourage the client to wear underwear made of cotton, which provides improved airflow through the perineal area. Underwear made from nylon traps moisture and provides an opportunity for bacterial growth. vii. Void before and after intercourse. viii. MY ix. The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection. x. 44. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. i. Disease processes: A history of gout and hypertension will not affect the results of the allergy skin testing. When reviewing a client's health record, the nurse should identify a history of diseases that alter the immune response as an interfering factor that can cause false negative results. ii. Laboratory findings: The client's laboratory values are within the expected reference ranges and are not an indication for postponing allergy skin testing. iii. Current medications: The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing. iv. Family history: allergy skin testing results can be affected by age; infants and older adult clients can have decreased reactivity to allergens. However, family history is not a factor in consideration for postponing allergy skin testing. v. 45. A nurse in and emergency department is reviewing the provider’s prescription for a client who sustained a rattlesnake bite to the lowe leg. Which of the following prescription should the nurse expect? a. Apply ice to the client’s puncture wounds b. Initiate corticosteroid therapy for the client c. Keep the client’s leg above the heart level d. Administer an opioid analgesic to the client i. Apply ice to the client's puncture wounds. ii. The nurse should apply ice for a bite from a black widow spider to reduce the action of the neurotoxin from the spider. iii. Initiate corticosteroid therapy for the client. iv. The nurse should expect a prescription for antihistamines and corticosteroids for stings from bees and wasps. v. Keep the client's leg above heart level. vi. The nurse should keep the affected extremity at heart level, not above or below it. vii. Administer an opioid analgesic to the client. viii. MY ix. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. 46. A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instruction should the nurse include? a. Keep the clients personal care items in the bathroom b. Keep the overhead lights on in the client’s bedroom while the client is sleeping c. Remind the client to scan their complete range of vision during ambulation d. Secure the client’s extension cords under carpeting. i. Keep the client's personal care items in the bathroom. ii. The nurse should instruct the client's family to keep the client's personal care items within the client's reach to reduce the risk for falls. iii. Keep the overhead lights on in the client's bedroom while the client is sleeping. iv. The nurse should instruct the family to use nightlights in the client's bedroom and bathroom to reduce the risk for falls. Keeping the overhead lights on while the client is sleeping can disrupt the client's circadian rhythm. v. Remind the client to scan their complete range of vision during ambulation. vi. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. vii. Secure the client's extension cords under carpeting. viii. MY ix. The nurse should instruct the client's family that they should secure extension cords to the client's baseboards using electrical tape, rather than placing them under carpeting. This practice can help to reduce the risk for falls. 47. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? a. A client who is receiving preoperative teaching for a right knee arthroplasty b. A client who states they will have difficulty obtaining a walker for home use c. A client who reports an increase in pain following a left hip arthroplasty d. A client who is having emotional difficulty accepting they have a prosthetic leg.\ i. A client who is receiving preoperative teaching for a right knee arthroplasty: The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions. ii. A client who states they will have difficulty obtaining a walker for home use: The nurse should make a referral to a social worker for a client who reports difficulty obtaining a walker for home use. iii. A client who reports an increase in pain following a left hip arthroplasty: MY ANThe nurse should contact the provider for a client who is experiencing increased pain following a left hip arthroplasty. iv. A client who is having emotional difficulty accepting that they have a prosthetic leg: The nurse should refer the client to a counselor to assist with coping with the adjustment to the need of a prosthetic leg. 48. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? a. Maintain adduction of the client’s legs b. Encourage ROM of the hip up to a 120 degree angle c. Place a pillow between the client’s legs d. Keep the client’s hip internally rotated i. Maintain adduction of the client's legs. ii. The nurse should assist the client to maintain their legs in abduction. iii. Encourage range of motion of the hip up to a 120° angle. iv. The client should not flex their hip greater than 90° to prevent hip dislocation. v. Place a pillow between the client's legs. vi. MY vii. The nurse should place a pillow between the client's legs to prevent hip dislocation. viii. Keep the client's hip internally rotated. ix. The nurse should not keep the client's hip internally rotated, as this can lead to hip dislocation. 49. A nurse and an AP are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? a. Wear a mask b. Wear a gown c. Keep the client’s room well lit d. Maintain the HOB at a 45 degree elevation i. Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy. ii. Wear a gown.: A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis does not spread via direct contact. iii. Keep the client's room well-lit.: Staff caring for this client should keep the illumination in the room dim and avoid bright light from windows to promote comfort and rest and avoid photophobia. iv. Maintain the head of the bed at a 45° elevation.: Staff caring for this client should keep the head of the bed at a 30° elevation. 50. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication a. Hypokalemia b. Hypercalcemia c. Gastrointestinal bleeding d. Confusion 51. Hypokalemia i. MY ii. Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration. iii. Hypercalcemia iv. Lactulose rids the body of excess ammonia and can result in hyponatremia if the client experiences diarrhea. It does not have any specific effects on calcium levels. v. Gastrointestinal bleeding vi. A client who has hepatic encephalopathy is at risk for gastrointestinal bleeding due to the decreased ability of the liver to produce clotting factors and the potential presence of esophageal varices. However, treatment with lactulose should not increase the risk for bleeding. vii. Confusion viii. Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. Because ammonia is a toxin that contributes to hepatic encephalopathy, effective treatment with lactulose should reduce confusion. b. 52. A nurse in an emergency dept is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? a. IV fluids b. Analgesia c. Antibiotics d. Tetanus toxoid i. IV fluids: ii. After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support. iii. Analgesia iv. The nurse should prepare to administer analgesia to manage the client's pain. However, evidence-based practice indicates that another action is the priority. v. Antibiotics vi. The nurse should prepare to administer antibiotics to prevent infection. However, evidence-based practice indicates that another action is the priority. vii. Tetanus toxoid: The nurse should prepare to administer tetanus toxoid. However, evidence-based practice indicates that another action is the priority. 53. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? a. Keep the line open with 0.9% sodium chloride until the new bag arrives b. Administer dextrose 10% in water until the new bag arrives c. Flush the line and cap the port until the new bag arrives d. Decrease the infusion rate until the new bag arrives. i. Keep the line open with 0.9% sodium chloride until the new bag arrives. ii. Infusing 0.9% sodium chloride can injure the client by causing an alteration in blood glucose levels. iii. Administer dextrose 10% in water until the new bag arrives. iv. TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level. v. Flush the line and cap the port until the new bag arrives. vi. The nurse should maintain an open IV line with an appropriate IV solution to prevent the client from experiencing an alteration in blood glucose levels. vii. Decrease the infusion rate until the new bag arrives. viii. MY ix. The nurse should continue infusing IV fluids with an appropriate IV to prevent the client from experiencing an alteration in blood glucose levels. x. 54. A nurse is caring for a client in an acute care facility who is at risk for seizures. Which of the following precautions should the nurse implement? a. Place a padded tongue blade at the client’s bedside b. Keep the side rails lowered on the client’s bed. c. Maintain the client’s bed at hip level or above d. Ensure that the client has a patent IV i. Place a padded tongue blade at the client's bedside. ii. The nurse should never insert a padded tongue blade in the client's mouth, because it can cause injury or occlude the client's airway. iii. Keep the side rails lowered on the client's bed. iv. The nurse should keep two or three side rails up on the client's bed to prevent falls. v. Maintain the client's bed at hip level or above. vi. The nurse should keep the client's bed in the lowest position to prevent falls. vii. Ensure that the client has a patent IV. viii. MY ix. The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity. 55. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? a. Add full-fat yogurt to the diet b. Add cabbage to the diet c. Replace butter with coconut oil d. Replace shellfish with red meat. i. add full-fat yogurt to the diet.: To help reduce the risk for colorectal cancer, the client should consume a diet that is low in fat and refined carbohydrates. Full-fat yogurt contains fat, and many yogurt products also contain refined sugar. ii. Add cabbage to the diet.: to help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber. iii. Replace butter with coconut oil.: to help reduce the risk for colorectal cancer, the client should consume a diet that is low in fat. Coconut oil, containing 100 g of fat per 100 g, is higher in total fat than butter, which contains 81 g of fat per 100 g. iv. Replace shellfish with red meat.to help reduce the risk for colorectal cancer, the client should avoid red meat because it is high in fat. The client's diet should contain lower-fat proteins, such as shellfish and poultry with the skin removed. 56. A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should Identify what which of the following client medications interacts with feverfew? a. Meoprolol b. Bupropion c. Naproxen d. Atorvastatin i. Metoprolol: metoprolol does not interact with feverfew. ii. Bupropion: bupropion does not interact with feverfew. iii. Naproxen: both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding. iv. Atorvastatin: the nurse should recognize that the effect of atorvastatin is decreased by St. John's wort. 57. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? a. "I will monitor my blood pressure while taking this medication." b. MY i. The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy. c. "I should take a vitamin D supplement to increase the effectiveness of the medication." i. The client requires an adequate intake of iron, folic acid, and vitamin B12 while taking this medication because they are essential to the production of erythrocytes. d. "I should inform the provider if I experience an increased appetite while taking this medication." i. Increased appetite is not an adverse effect of epoetin alfa. Adverse effects of epoetin alfa include seizures, heart failure, myocardial infarction, stroke, thrombolytic event, and hypertension. e. "I will decrease the amount of protein in my diet while taking this medication." i. The client should increase the amount of protein in their diet while receiving chemotherapy to decrease the risk for infection. 58. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication a. Bradycardia b. Tremors c. Orthostatic hypotension d. drowsiness i. Bradycardia 1. The nurse should identify that tachycardia, not bradycardia, is an adverse effect of enalapril. ii. Tremors 1. A client who is taking enalapril can experience dizziness rather than tremors. iii. Orthostatic hypotension 1. The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril. iv. Drowsiness v. MY 1. The nurse should identify insomnia as an adverse effect of enalapril. 59. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? a. Serum sodium level 145 mEq/L b. A serum sodium level of 145 mEq/dL is within the expected reference range. A sodium level higher than the expected reference range, or greater than 145 mEq/L, can be an indication of excessive free water loss resulting in hypertonic dehydration. c. Forearm skin tents when pinched d. MY e. Skin turgor can be an unreliable indication of dehydration in older adult clients because of age-related changes to skin elasticity. The nurse should check an older adult client's skin turgor on the sternum, rather than on the limbs, for a more reliable indicator. f. Respiratory rate decreased g. The nurse should expect the client's respiratory rate to increase if dehydration occurs because the decreased vascular fluid volume seen with dehydration decreases oxygenation and organ perfusion, requiring a compensatory increase in the respiratory rate. h. Urine specific gravity 1.045 i. A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. 60. a nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a. Insert a padded tongue blade. i. The nurse should not insert anything into the client's mouth during the seizure. A tongue blade can create a choking hazard and cause injury to the client's teeth and mouth. b. Apply oxygen. i. Clients who experience a tonic-clonic seizure can become hypoxic for brief intervals and may be offered in the postictal phase, but supplemental oxygen is not usually necessary. c. Restrain the client. i. The nurse should not restrain the client in any way during the seizure but should instead clear the area of objects close to the client to prevent injury. d. Loosen restrictive clothing. e. MY i. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation. 61. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? a. "It is just easier to let my partner administer my insulin." i. This statement does not indicate that the client is successfully coping with the change. b. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." c. MY i. This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications. d. "I'm concerned I won't be able to read my blood sugar level because the screen is so small." i. This statement does not indicate that the client is successfully coping with the change. The nurse should provide the client with a monitor that has a larger screen. e. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to." i. This statement does not indicate that the client is successfully coping with the change. 62. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? a. Check laboratory values for recent hemoglobin and hematocrit levels. b. The nurse should check the client's most recent laboratory results, including hemoglobin and hematocrit levels, as these provide information regarding the need for eventual blood product replacement. However, there is another action the nurse should take first. c. Establish a peripheral IV line for possible transfusion. d. Although the nurse should initiate a peripheral IV line for saline or blood administration, there is another action the nurse should take first. e. Call the laboratory to obtain a stat platelet count. f. Although drawing the client's blood to check for a low platelet count is important because a low platelet level indicates problems with blood clotting, there is another action the nurse should take first. g. Obtain vital signs. h. MY i. The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making. 63. A nurse is providing discharge teaching to a client who has heart failure and a new prescriptions for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? a. Try to walk at least three times per week for exercise. b. The development of a regular exercise routine can improve outcomes in clients who have heart failure. c. To increase stamina, walk for 5 min after fatigue begins. d. Walking for 5 min after the onset of fatigue will not increase stamina and can exacerbate the client's heart failure. e. Take over-the-counter cough medicine for persistent cough. f. The provider should approve the use of over-the-counter cough medication for a persistent cough prior to use. A persistent cough can exacerbate the client's heart failure. g. Use a salt substitute to reduce sodium intake. h. MY i. Salt substitutes contain an increased amount of potassium, which can place the client at an increased risk for hyperkalemia. 64. A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide? a. Increase fluid intake.:increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test. b. Take an over-the-counter antidiarrheal medication: taking an over-the-counter antidiarrheal following an upper gastrointestinal series would slow the elimination of the barium used during the test. The nurse should instruct the client to take a laxative. c. Expect black, tarry stools.: the client should expect stools to appear chalky white until the barium is completely eliminated, which typically takes between 24 and 72 hr. Black, tarry stools are an indication of gastrointestinal bleeding. d. Follow a low-fiber diet.: a low-fiber diet, used to treat diarrhea, does not facilitate the elimination of the barium used during the test. The nurse should recommend an increase in fiber intake instead. 65. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include with the teaching? "It is an expected effect to sleep through the day when taking this medication." The nurse should instruct the client to report oversedation, which increases the risk for respiratory depression. "Your constipation will be lessened as you develop a tolerance to the medication." The nurse should instruct the client that constipation is an adverse effect of opioid analgesics and can be managed by increasing intake of fiber. "You should void every 4 hours to decrease the risk of urinary retention." The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics. "If you experience ringing in your ears, your dose will need to be reduced."Many medications, including aspirin and aminoglycosides, can cause ringing of the ears, but this is not an adverse effect of opioid analgesics. 66. A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? a. 67. A nurse is providing preoperative teaching to a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? i. Teach the importance of a clear liquid diet after discharge. ii. MY iii. The nurse should teach the client to advance to solid foods with the return of peristalsis, which usually occurs within 1 to 2 days after surgery, and to introduce foods high in fat one at a time to determine tolerance. iv. Tell the client to remove the incisional adhesive strips 3 days after discharge. v. The nurse should tell the client that the incisional adhesive strips will begin to fall off 7 to 10 days after application and that the provider might remove the adhesive strips during that timeframe. vi. Demonstrate ways to deep breathe and cough. vii. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications. viii. Instruct the client to maintain bed rest for 48 hr. ix. The nurse should instruct the client to ambulate as soon as possible to prevent postoperative complications, such as deep-vein thrombosis or pneumonia. b. 68. A nurse in in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? i. "It's like a curtain closed over my eye." ii. MY iii. A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field. iv. "This sharp pain in my eye started 2 hours ago." v. Clients who have a retinal detachment may report seeing sudden flashes of light, a sensation of a curtain being pulled over the eye, or floating dark spots. Retinal detachment is usually painless. vi. "I've been having more and more difficulty seeing over the last few weeks." vii. Retinal detachment usually has a sudden onset. viii. "I seem to have more problems seeing different colors." ix. Clients who have cataracts experience a loss in color perception. However, this is not a manifestation of retinal detachment. b. 69. A home health nurse is assigned to a client who was recently discharged from a rehab center after experiencing a right-hemispheric stroke. Which of the following neuro deficits should the nurse expect to find when assessing the client? a. Expressive aphasia is incorrect. Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke. Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. Right hemiplegia is incorrect. Right hemiplegia occurs secondary to a left-hemispheric stroke. One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke. 70. 71. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing a client? i. "Take insulin even if you are unable to eat your regular diet." ii. MY iii. The client should continue the prescribed medication regimen when ill to prevent hyperglycemia. iv. "It's okay if your ketone levels are temporarily high." v. The client should notify the provider if moderate to large amounts of ketones appear in the urine. vi. "Monitor your blood glucose levels every 12 hours." vii. The client should monitor blood glucose levels at least every 4 hr when ill. viii. "Call the provider if your glucose levels reach 170 milligrams per deciliter." ix. The client should notify the provider if their blood glucose level is greater than 250 mg/dL. b. 72. A nurse is caring for a client who has a new prescription for TPN. The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/l. the IV pump should be set at how many ml/hr? Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired Over Have method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 4,000 mL Step 3: What is the total infusion time? 24 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL) X mL/hr = Time (hr) 4,000 mL X mL/hr = 24 hr X mL/hr = 166.67 Step 6: Round if necessary. 166.67 = 167 mL/hr 73. A nurse is assessing a client who had extracorporeal show wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? i. Stone fragments in the urine: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones. ii. Fever: Fever following ESWL is a complication that is a result of micro-organisms from an underlying urinary tract infection colonizing or pyelonephritis. iii. Decreased urine output: A decrease in urine output following ESWL is a complication caused by stone fragments obstructing urine flow. iv. Bruising on the lower abdomen: bruising on the lower back or flank of the affected side is caused by the repeated shock waves directed toward the body during the ESWL procedure. 74. A nurse has received change of shift report for a group of clients. Which of the following should the nurse assess first? i. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a scale of 0 to 10 ii. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a scale of 0 to 10 is stable because pain following surgery is an expected finding. Therefore, there is another client the nurse should assess first. iii. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet iv. MY v. When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI. vi. A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and reports severe itching vii. A client who has atopic dermatitis with scaling and excoriation of the skin and reports severe itching is stable because these are expected findings. Therefore, there is another client the nurse should assess first. viii. A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds ix. A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds is stable because these are expected findings. Therefore, there is another client the nurse should assess first. 75. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hrs ago. Which of the following actions should the nurse take? i. Inspect the cast for drainage once every 24 hr. ii. The nurse should inspect the cast for drainage and alignment at least once every 8 to 12 hr. iii. Check that one finger fits between the cast and the leg. iv. MY v. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. vi. Perform neurovascular checks every 2 to 3 hr. vii. For the first 24 hr after cast application, the nurse should check the neurovascular status of the client's leg every hour. The nurse does this by assessing sensation, motion, and circulation. viii. Make sure the client has a warm blanket covering the cast. ix. The nurse should make sure the cast is uncovered to allow for thorough air drying of the plaster. Also, the heat that is generated by the drying process has to escape. 76. A nurse is providing teaching to an older female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? i. "I am taking my progesterone daily." ii. Topical estrogen, not progesterone, can improve the circulation of blood to the perineal area and improve the tone of the periurethral muscles for a client who has experienced menopause. iii. "I am dieting to lose weight." iv. MY v. Excess weight creates increased abdominal pressure that can result in stress incontinence. vi. "I am limiting my daily fluid intake." vii. The client should maintain adequate intake of water for proper kidney function and hydration. viii. "I have switched my morning cups of coffee to hot tea." ix. A client who has stress incontinence should avoid intake of caffeine because it is a bladder irritant. Many tea and coffee beverages contain caffeine. 77. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? i. Restlessness ii. Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. iii. T3 level 215 ng/dL iv. An elevated T3 level is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. v. Blood pressure 170/80 mm Hg vi. MY vii. Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm. viii. Decreased weight ix. Decreased weight is nonurgent because it is an expected finding for a client who has hyperthyroidism. Therefore, there is another finding that is the priority to report. 78. A nurse is caring for a client who is experiencing superventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, BP 78/40, RR 30/min. Which of the following actions should the nurse take? i. Defibrillate the client's heart. ii. The nurse should defibrillate the client's heart for ventricular tachycardia or ventricular fibrillation. iii. Perform synchronized cardioversion. iv. MY v. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia. vi. Begin cardiopulmonary resuscitation. vii. The nurse should initiate CPR for a client who is pulseless or not breathing. viii. Administer lidocaine IV bolus. ix. The nurse should administer lidocaine IV bolus for a client who has a ventricular dysrhythmia. 79. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates and understanding of the teaching? i. "I should take calcium supplements so the medication will work better in my system." ii. A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal. iii. "I am taking this medication to increase my energy level." iv. MY v. The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance. vi. "This medication can cause my blood pressure to drop." vii. Therapy with erythropoietin increases RBC production, which can result in hypertension, not hypotension. viii. "I will not need to restrict protein in my diet while taking this medication." ix. Erythropoietin does not affect the client's protein requirements, but the client should continue to restrict protein as prescribed by the provider to manage kidney disease. 80. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? i. Monitor the client's temperature every 4 hr. ii. The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection. iii. Insert an indwelling urinary catheter for the client. iv. The nurse should avoid the insertion of an indwelling urinary catheter for a client who has neutropenia because it can greatly increase the client's risk for an infection. v. Request the client's bathroom to be cleaned three times each week. vi. The nurse should ensure that the client's room and bathroom are cleaned at least once each day, rather than three times each week, to decrease the client's risk for infection. vii. Place a box of latex gloves just outside the client's room. viii. MY ix. The nurse should keep a dedicated box of disposable gloves in the client's room to decrease the risk of contamination, which can lead to infection. 81. A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent Pseudomonas aeruginosa infection? i. Encourage the client to eat raw fruits and vegetables. ii. The nurse should identify that P. aeruginosa can be found in raw fruits and vegetables. iii. Avoid placing plants or flowers in the client's room. iv. MY v. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room. vi. Limit visitors to members of the client's immediate family. vii. The nurse does not need to limit visits to family members. However, the nurse should prohibit visits from those at risk for P. aeruginosa infection, such as anyone who is ill, other hospitalized clients, and small children. viii. Wear an N95 respirator mask when providing care to the client. ix. P. aeruginosa spreads by contact, either on health care workers' hands or contaminated equipment. It is not airborne, so respirator masks are unnecessary. 82. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? a. "You will still have the urge to void." b. During the procedure, the client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma, from which urine will flow into an external ostomy bag. Therefore, the client will not have an urge to void. c. "You can apply an aspirin tablet to the pouch to reduce odor." d. MY e. The client should not add an aspirin tablet to the pouch, because it can ulcerate the stoma. f. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." g. The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine. h. "You should use a moisturizing soap when washing the skin around the stoma." i. The client should avoid using moisturizing soaps to clean the skin around the stoma because it will prevent the pouch from adhering to the skin. 83. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? a. Compare both testicles by examining them simultaneously. b. The nurse should instruct the client to use both hands to examine each testicle separately. c. Roll each testicle between the thumb and fingers. d. MY e. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle. f. Perform testicular self-examination before a warm bath or shower. g. The nurse should inform the client that testicle self-examination should be performed either during or after a warm bath or shower. h. Perform self-examination of the testicles every 2 weeks. i. It is unnecessary to self-examine the testicles every 2 weeks. Once a month is sufficient. 84. A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effect should the nurse monitor? a. Hyperreflexia c. Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of magnesium sulfate. d. Increased blood pressure e. Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension. f. Respiratory paralysis g. The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate. h. Tachycardia i. Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate. 85. A nurse is caring for a client who has diabetic ketoacidosis DKA. Which of the following laboratory findings should the nurse expect? a. Negative urine ketones b. A client who has DKA experiences ketosis, which results in ketones in the urine and blood. c. BUN 32 mg/dL d. DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine. e. pH 7.43 f. MY g. The nurse should expect a client who has DKA to have a pH level less than 7.35 due to the increased production of ketones, which results in metabolic acidosis. The client might exhibit Kussmaul respirations, which are deep and rapid respirations that compensate for the decreased pH. Sodium bicarbonate is administered for severe acidosis when the client's pH level is less than 7. h. HCO3- 23 mEq/L i. The nurse should expect a client who has DKA to have an HCO3- less than 15 mEq/L. This decreased value is due to an increased production of ketones, resulting in metabolic acidosis. 86. A nurse is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate that the client is having an adverse reaction to this medication? a. Report of a night cough b. MY c. The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider. d. Report of tinnitus e. Propranolol is a nonselective beta-adrenergic antagonist that has sensory effects, including dry eyes and vision changes. However, tinnitus is not an adverse effect of propranolol. f. Report of excessive tearing g. Propranolol is a nonselective beta-adrenergic antagonist that can affect the heart, the lungs, and the eyes. Ophthalmic adverse effects include blurred vision and dry eyes. h. Report of increased salivation i. Propranolol is a nonselective beta-adrenergic antagonist that has several gastrointestinal effects, such as dry mouth, abdominal cramping, constipation, and diarrhea. 87. A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? a. Nonrebreather mask b. MY c. The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask. d. Venturi mask e. The nurse should initiate a Venturi mask for a client who requires an exact oxygen flow. A Venturi mask can only deliver an oxygen concentration between 24% and 50%. f. Simple face mask g. The nurse should initiate a simple face mask for a client who requires short-term supplemental oxygen. A simple face mask can only deliver an oxygen concentration between 40% and 60%. A simple face mask does not usually fit well and can lead to skin breakdown. h. Partial rebreather mask i. The nurse should initiate a partial rebreather mask for a client who can sustain adequate oxygen saturation levels with a mixture of room air and oxygen. A partial rebreather allows a portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to a range between 60% and 75%. 88. A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan? a. Remind the client that dialysis treatments are not difficult to incorporate into daily life. b. The nurse should inform the client of the difficulty of incorporating dialysis into daily life to allow the client to develop realistic expectations. c. Inform the client that dialysis will result in a cure. d. The nurse should inform the client that dialysis is not a cure and is a life-long management for chronic kidney disease. e. Tell the client that it is possible to return to similar previous levels of activity. f. MY g. The nurse should help the client develop realistic goals and activities to have a productive life. h. Begin health promotion teaching during the first dialysis treatment. i. The nurse should begin health and lifestyle teaching in the first weeks after starting the dialysis treatment once the client feels better physically and emotionally. 89. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted.” Which of the following actions should the nurse take? a. Administer a placebo to the client without their knowledge. b. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights. c. Instruct the client on alternative therapies for pain reduction. d. MY e. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction. f. Tell the client not to worry about addiction to prescribed narcotics. g. This response by the nurse is nontherapeutic because it dismisses the client's concerns. h. Suggest the client receive a different opioid for pain reduction. i. By suggesting the client receive a different opioid for pain reduction, the nurse is disregarding the client’s concerns about opioid use disorder. 90. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? a. Dysphagia b. MY c. Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding. d. Aphasia e. Aphasia indicates that the client is at risk for communication impairment. However, another finding is the priority. f. Ataxia g. Ataxia indicates that the client is at risk for injury from falling. However, another finding is the priority. h. Hemianopsia i. Hemianopsia indicates the client is at risk for injury when ambulating. However, another finding is the priority. 91. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? a. Decreased T cells b. T cells are responsible for cellular immunity. The T cell count indicates the body's ability to fight opportunistic infections and cancer. A decreased T cell count indicates the progression of HIV. Once the T cell count falls below 200 cells/mm3, the client receives a diagnosis of AIDS. c. Increased creatinine clearance d. Creatinine clearance measures the ability of the kidneys to filter the blood. An increased creatinine clearance level indicates compromised renal function, which is a common occurrence in clients who have HIV. e. Increased eosinophils f. Eosinophils are a type of leukocyte that are responsive to parasitic infections and allergic reactions. An increase in eosinophils indicates the presence of infection. g. Decreased viral load h. MY i. Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment. 92. A nurse in an emergency department is caring for a client who is experiencing Thyroid Storm. Which of the following manifestations should the nurse expect? a. Fever is correct. The nurse should expect the client to have a fever because of the excessive thyroid hormone release. Nonpitting edema is incorrect. Nonpitting edema is a manifestation of myxedema coma, a complication of hypothyroidism. Hypertension is correct. The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release. Tachycardia is correct. The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release. Hypoglycemia is incorrect. Hypoglycemia is a manifestation of myxedema coma, a complication of hypothyroidism. 93. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? a. Metabolic alkalosis b. A client who has chronic glomerulonephritis can experience metabolic acidosis as a result of bicarbonate loss and retention of hydrogen ions. c. Hyperkalemia d. MY e. The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium. f. Increased hemoglobin g. A client who has chronic glomerulonephritis can experience anemia as a result of decreased RBC production. h. Hypophosphatemia i. A client who has chronic glomerulonephritis can experience hyperphosphatemia as a result of decreased excretion of phosphorus through the kidneys. 94. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s triad? a. Hypotension b. A client who has increased intracranial pressure from a traumatic brain injury can develop hypertension, which is one component of Cushing's triad. c. Tachypnea d. A client who has a traumatic brain injury can develop decreased cerebral blood flow, which results in increased arterial pressure. The changes to arterial pressure cause changes in blood pressure. However, respirations are not affected. e. Nuchal rigidity f. Nuchal rigidity, or neck stiffness, is an indication of meningitis. g. Bradycardia h. MY i. A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure. 95. A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction? Which of the following statements should the nurse make? a. "You might need to take a stool softener while taking this medication." b. Sildenafil can cause diarrhea, rather than constipation. c. "You will not be able to use sildenafil if you have diabetes." d. Diabetes mellitus is not a contraindication for the use of sildenafil. Clients who have renal, hepatic, or cardiovascular disease should use sildenafil cautiously. e. "You will need to limit your caffeine intake if you start taking sildenafil." f. A client who is taking sildenafil does not need to limit caffeine intake. However, high-fat meals can decrease absorption of the medication. g. "You will not be able to use sildenafil if you are taking nitroglycerin." h. MY i. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension. 96. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? a. Take an antacid before meals and at bedtime. b. Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and pain associated with diarrhea and constipation. Anticholinergic or antispasmodic agents can be prescribed to control cramping. c. Increase fiber intake to at least 30 g per day. d. MY e. Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns. f. Drink ginger tea daily. g. Ginger tea is useful for treating nausea, not cramping. Additionally, a client who has IBS should avoid dairy products, raw fruits, and grains that can cause bloating. h. Consume no more than 1 L of water per day. i. The client should consume at least 2 L of water daily to promote regular bowel function. 97. A nurse is caring for a client who is on bed rest and has new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? a. Monitor the client's INR daily. b. A client who is taking enoxaparin does not require a daily INR. The nurse should periodically compare the client's CBC with a baseline CBC. c. Expel air bubbles when using a prefilled syringe. d. MY e. The nurse should plan to follow the injection of the medication with the air bubble located at the site of the plunger in the prefilled syringe. The air bubble ensures that the client receives the whole dose of the medication. f. Inject the medication into the anterolateral abdominal wall. g. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation. h. Massage the injection site after administration. i. The nurse should avoid massaging the client's injection site after administration to minimize bruising. 98. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nuse should instruct the client that the medication provides relief by which of the following actions? a. Neutralizing gastric acid b. Antacids, such as aluminum hydroxide, neutralize gastric acid. c. Reducing the growth of ulcer-causing bacteria d. Antibiotics, such as amoxicillin, reduce the growth of ulcer-causing bacteria Helicobacter pylori. e. Coating the stomach lining f. Anti-ulcer medications, such as sucralfate, coat the stomach lining and adhere to the ulcer site. g. Suppressing gastric acid production h. MY i. Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production. 99. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? a. Amylase b. An elevated amylase level is an expected finding in a client who has pancreatitis due to injured pancreatic cells. c. Alkaline phosphatase d. An elevated alkaline phosphatase level is an expected finding in a client who has pancreatitis with biliary involvement. e. Bilirubin f. An elevated bilirubin level is an expected finding in a client who has pancreatitis with biliary involvement. g. Calcium h. MY i. A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis 1. A nurse is assessing group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? a. A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose b. The client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose can remain independent and active and is not at risk for experiencing a role change. c. A client who had a cholecystectomy and is starting on a modified-fat diet d. The client who had a cholecystectomy with a diet change can remain independent and active and is not at risk for experiencing a role change. e. A client who has Crohn's disease and is experiencing diarrhea three times a day f. The client who has Crohn's disease and is experiencing diarrhea can remain independent and active and is not at risk for experiencing a role change. g. A client who has multiple sclerosis and is experiencing progressive difficulty ambulating h. MY i. The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent. 2. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. a. The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair. 3. A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notices that part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? a. Place the client in a supine position. b. The nurse should place the client in a supine position to promote blood flow to the vital organs. However, evidence-based practice indicates that another action is the priority. c. Measure vital signs. d. The nurse should measure the client's vital signs to monitor for complications. However, evidence-based practice indicates that another action is the priority. e. Cover the wound with a sterile, saline-moistened dressing. f. MY g. The nurse should cover the wound with a sterile, saline-moistened dressing to protect the organs. However, evidence-based practice indicates that another action is the priority. h. Call for help. i. Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance. j. [Show More]

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