Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver
A. use reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. A and B are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a written record may not be available or currently accurate.
A client who has just tested positive for HIV does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection?
A. teach the client about the medications that are available for treatment
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners
B. discuss retesting to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about A, B, and C, retesting encourages the client to maintain medical follow-up and management.
The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC). what is the most significant desired outcome for this client?
A. free from injury of drug side effects
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight
D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long management problem. Client outcomes for adequate oxygenation are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food
a. assist the client to ambulate in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and distention minimized by implementing early and frequent ambulation. Based on the client's status, laxatives or withholding dietary progression are not indicated at this time. although pain management should be implemented, another analgesic prescription may be needed because morphine reduces intestinal motility and contributes to the client's gas pains.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement?
A. keep the head of the bed elevated 30 degrees
B. turn off the television and darken the room
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours
B. turn off the television and darken the room
to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. Turning off the television and darkening the room minimize fluorescent lights, flickering television lights, and distracting sound. The other are ineffective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period?
A. check vital signs every 15 minutes for 2 hours
B. allow the client nothing by mouth until the gag reflex returns
C. encourage fluid intake to promote elimination of the contrast media
D. keep the client on bed rest for 8 hours
B. allow the client nothing by mouth until the gag reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. The others are not indicated after bronchoscopy
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. to evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of clear water
D. assess for respiratory distress
A. observe the client four coughing colored sputum after drinking a small amount of colored water
to evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then be observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water.
What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment?
A. vesicular breath sounds decrease
B. wheezing becomes louder
C. bronchodilators stimulate coughing
D. cough remains unproductive
B. wheezing becomes louder
In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive. vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields.
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement?
A. limit the client's intake of oral fluids
B. teach the client about prevention of crises
C. evaluate the effectiveness of narcotic analgesics
D. encourage the client to ambulate as tolerated
C. evaluate the effectiveness of narcotic analgesics
Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. What action should the nurse implement?
A. provide oral hygiene every 2 hours
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood
D. check stools for occult blod
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client is admitted for complaints of chest pain and aching for the past 4 days. the results for serum creatine kinase-MB (CK-MB) and troponin are obtained. What rationale should the nurse use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm myocardial damage
B. myocardial damage that occurred several days earlier is best validated by serum troponin levels
C. the most reliable indicator of myocardial necrosis is serum CK-MB
D. serum cardiac markers are inconclusive in determining myocardial injury after waiting several days
B. myocardial damage that occurred several days earlier is best validated by serum troponin levels
Serum CK-MB and troponin are the two most important serum cardiac markers for confirming myocardial infarction. CK-MB begins to rise in the first 3 to 12 hours after the myocardial infarction, peaks in 24 hours, and returns to normal in 2 to 3 days. the troponin level rises as quickly but remains elevated for 2 weeks.
Three weeks after discharge fro an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states "I guess we will never have sex again after this." Which response is best for the nurse to provide?
A. sexual activity can be resumed whenever you and you wife feel like it because the sexual response is more emotional rather than physical
B. you should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage
C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities
D. sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife
C. sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities
sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, as long as other guidelines, such as limiting food and alcohol intake before intercourse, are followed.
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this devise will help him. How should the nurse explain the action of a synchronous pacemaker?
A. an impulse is fired every second to maintain a heart rate of 60 beats per minute
B. ectopic stimulus in the atria is suppressed by the device of usurping depolarization
C. ventricular irritability is prevented by the constant rate setting of a pacemaker
D. an electrical stimulus is discharged when no ventricular response is sensed
D. an electrical stimulus is discharged when no ventricular response is sensed
The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmia like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. what information is best for the nurse to provide?
A. smoking can decrease the quantity and quality of sperm
B. the first semen analysis should be repeated to confirm sperm counts
C. only marijuana cigarettes affect sperm count
D. cessation of smoking improves general health and fertility
E. sperm specimens should be collected in 2 subsequent days
A, B, and D
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity, so a single analysis may be inconclusive. A minimum o two analyses should be performed several weeks apart to assess male fertility.
A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide?
A. "talk only to other friends who are infertile since only they can help"
B. "tell your friends and family so that they can help you"
C. "get involved in a support group. I will give you some names"
D. "start adoption proceedings immediately since obtaining an infant is very difficult"
C
A support group provides a safe haven for the couple to share experiences and gain insight from others' experiences. Although talking about feelings may unburden the couple of negative feelings, infertility is a major stressor that affects the couple's relationships, so discussion with family and friends should be minimal. Limiting interaction to other infertile couples may address some psychosocial needs, but depending on where the other couples are in the recovery process, it may not be helpful. Giving an opinion about adoption is not therapeutic nor supportive of the psychosocial needs.
The nurse is providing post-operative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan?
A. avoid lifting more than 4.5 kg (10 lb) or reaching above her head
B. empty surgical drains once a week using procedural gloves
C. report inflammation of the incision site or the affected arm
D. wearing clothing with snug sleeves over the arm on the operative side
A and D
Part of the client's teaching plan should include reporting evidence of inflammation at the incision or of the affected arm and to avoid lifting or reaching, which places the client at risk for injury to the extremity that may have compromised lymphatic drainage. the client should be instructed to empty surgical drains daily, no weekly. Activity that decreases circulation in the affected arm, such as carrying a handbag over the shoulder, wearing tight clothing, or tight jewelry, should be avoided.
the nurse directs an unlicensed assisstive personnel (UAP) to obtain vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP?
A. elevate the arm with an IV infusing on the operative side with a pillow
B. apply the blood pressure cuff to the arm on the non-operative side
C. position the arm on the operative side close to the body
D. collect a fingerstick blood specimen from the arm on the operative side
B.
Blood pressure reading should be obtained from the arm on the unoperative side to reduce the risk of injury of the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage, not close to the body. An IV infusion or blood specimen collection should not involve the use of the arm on the operative side.
Which client is at the highest risk for compromised psychological adjustment after a hysterectomy?
A. a 62-year-old widow who has three friends who had uncomplicated hysterectomies
B. A 29-year-old woman whose uterus ruptured after giving birth to her first child
C. A 46-year-old woman with three children and a recent promotion at work
D. A 55-year-old woman with abnormal bleeding and pain for 3 years
B
The client who is a primipara and is still in her childbearing years is at highest risk for unresolved conflicts about the end of her childbearing opportunities. The client with a family and positive life events, the menopausal client with physical distress, the post-menopausal client with support of peers with similar positive outcomes are less likely to be psychologically distressed.
A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed?
A. "I have asked my daughter to stay with me next week after I am discharged"
B. "Well, I don't have to worry about getting pregnant anymore"
C. "I know I will miss having sexual intercourse with my husband"
D. "I can't wait to go on the cruise that I have planned for this summer"
C
further teaching is needed in response to the client's misunderstanding of sexuality after a hysterectomy that is reflected in the statement. the client's knowledge about reproduction, a positive outlook with plans for the future, and her anticipated need for assistance and support during recovery indicate she understands the present status of her recovery.
A client in the pre-operative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement?
A. give the drug and allow the client to read and sign the consent form
B. withhold the drug until the client validates understanding of the surgical procedure and signs the consent form
C. counter-sign the client's initials on the consent form after giving the drug
D. call the healthcare provider to explain the surgical procedure before the client signs the consent
B
Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered. The validity of legal documents will be in question if a client signs them while under the influence of any central nervous system depressant drug.
A client with acute osteomyelitis has undergone surgical debridement of the diseased boen and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate?
A. parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks
B. parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year
C. oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis
D. parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks
D
Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
A client with osteoarthritis request information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information?
A. repetitive strength-building exercises with weights or resistance bands
B. high-impact aerobic exercise
C. circuit training alternating with frequent rest periods
D. low impact exercise, walking, swimming and water aerobics
D
Low impact exercises such as walking or swimming, that do not cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan?
A. enemas are given to empty the bowel after the procedure
B. the xray procedure may last for several hours
C. a nasogastric tube (NGT) is inserted to instill the barium
D. nothing by mouth is allowed for 6 to 8 hours before the study
D
The client should be NPO for at least 6 hours before the UGI. A NGT is not needed to instill the barium unless the client is unable to swallow. A laxative, not enemas, is given after the procedure to help expel the barium
The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different?
A. diameter of the tubes
B. procedure for feedings
C. method of insertion
D. location of the tubes
C
The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incisions in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a stab wound in the abdominal wall.
The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to the client?
A. it does not dilate the stomach
B. it does not cause diarrhea
C. it is slow to leave the stomach
D. it is quickly digested
C
This type of diet is slowly digested and is slow to leave the stomach. Because of its density from proteins and fats, and the reduction of fluids with the meal, the possibility of dumping syndrome is reduced.
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement?
A. position on the left side with knees drawn up
B. Encourage ice chips sparingly
C. administer anti-emetics every 2 to 3 hours
D. give IV fluids with electrolytes
D
When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered.
What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home?
A. maintain sterile technique
B. drink 500 mL of fluid within 2 hours of catheterization
C. use the Cred maneuver before catheterization
D. catheterize every 3 to 4 hours
D
The average interval between catheterization for adults is every 3 to 4 hours. Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home.
A client's prostate-specific antigen (PSA) exam result showed a PSA density o 0.13 ng/ml. Which conclusion regarding this lab data is accurate?
A. biopsy of the prostate is indicated
B. probably prostatitis
C. low risk for prostate cancer
D. the presence of cancer cells
C
Clients with a PSA density of less than 0.15 ng/ml are considered at low risk for prostate cancer.
The nurse is caring for a client after a transurethral resection of the prostate and determines the client's urinary catheter is not draining. What should the nurse implement?
A. encourage the client to drink oral fluids
B. change drainage unit tubing
C. irrigate the catheter
D. reposition the catheter drainage tubing
C
Obstruction urinary flow after a TURP is most often due to blood clot, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands?
A. increased frequency of assessment for prostatic cancer is needed
B. ongoing antibiotic therapy is needed for one year
C. the client should not undergo magnetic resonance imaging
D. the client should not be catheterized though the stent for at least three months
D
To prevent complications, the client should be cautioned against catheterization through the stent for three months after stent placement. Long term antibiotic use for one year is not a part of illness management. There is no contraindication for magnetic resonance imaging. Frequent assessment of prostate health is part of client teaching for health promotion, but is not increased because of the stent placement
A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication?
A. sensitivity to sunlight
B. muscle fascicultations
C. increased urinary frequency
D. gastrointestinal disturbance
D
Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this drug be taken with food to avoid gastrointestinal upset. Naproxen does not cause sensitivity to sunlight, muscle fasicultations, or urinary frequency.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include?
A. permanent pigment changes to the breast may result
B. there is a possibility of long bone pain
C. dry, itchy, skin changes may occur
D. a low-residue diet may be ordered to reduce the likelihood of diarrhea
C.
Side effects from radiation to the breast most often include temporary skin changes such as: dryness, tenderness, redness, swelling, and pruritis
The nurse is caring for a client receiving tamoxifen (Nolvadex) for treatment of breast cancer. Which action should the nurse include in the client's plan of care?
A. encourage milk products to increase calcium intake
B. monitor sodium chloride intake
C. increase fluid intake
D. assist the client in coping with hot flashes
D
Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so it should be included in the plan of care. Increasing fluid intake, monitoring sodium intake, and encouraging milk products to increase calcium intake re not related to the care of a client receiving tamoxifen
The nurse assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further?
A. increase in muscle tone but decreased muscle strength
B. increase in abdominal fat deposits
C. thinning hair and dry scalp
D. increase in appetite and taste-bud acuity
B
An increase in the abdominal girth may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common finding include thinning hair, dry skin and scalp, changes in taste bud acuity, and muscle size and strength, which are consistent with normal system functioning during aging.
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit?
A. tell another staff member to bring extinguishing equipment to the bedside
B. implement an emergency protocol to remove the client from the ventilator
C. use a bag-valve-mask resuscitator while removing the client from the area
D. close the doors to the client's area when attempting to extinguish the fire
C
A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source. the other are not the priority in maintaining safety during a fire int he client care area.
The nurse is planning pre-operative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client?
A. prognosis after treatment is excellent
B. the stoma should never be covered after this type of surgery
C. there is a radical change in appearance as a result of this surgery
D. techniques for esophageal speech are relatively easy to learn with practice
C
Radical neck dissection is the removal of lymphatic drainage channel and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured.
In planning care for a client with an acute stroke resulting in right-side hemiplegia, which positioning should the nurse use to maintain optimal functioning?
A. supine with trochanter rolls to the hips
B. left lateral, supine, brief periods on the right side, and prone
C. sim's position alternated with right lateral position q2 hours
D. mid-fowler's with knees supported
B
After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and include the prone position to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulating.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?
A. perform active range of motion three times daily
B. monitor for Battle's sign every four hours
C. teach measures to avoid the Valsalva maneuver
D. maintain the head of bed in a flat position
C
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels. Passive, not active ROM is performed to avoid ICP, bleeding and rupture. Battle's sign, bruising noted behind the ear, is a manifestation that may be seen with a basilar skull fracture, not hemorrhagic stroke. The flat position for the head of the bed is avoided because it increase venous congestion and ICP
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure?
A. provide a clear-liquid diet 48 hours before the procedure
B. initiate pre-operative sedation
C. begins fast the morning of the procedure
D. administer an enema before the procedure
E. obtain consent for the procedure
A, C, D, E
The usual pre-operative preparation for this procedure entails obtaining the client's consent to the procedure, a clear-liquid diet 24-48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure. Pre-operative sedation is not he norm for this procedure, although some healthcare providers administer a mild tranquilizer
The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration?
A. hypersecretion of hydrochloric acid
B. vagal stimulation
C. an increased level of stress
D. an increased number of parietal cells
E. decreased duodenal inhibition
A, B, D, E
Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids. An increase stress level is not physiologic and is not a direct cause of ulceration
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings?
A. flushing the tube with 50 ml of normal saline solution after each feeding
B. assessing residual amounts once a day
C. changign the enteral-feeding bag every 24 hours
D. keeping the head of the bed elevated 30 degrees
E. checking the placement of the tube by means of gastric aspiration
A, C, D, E
Keeping the head of the bed elevated 30 degrees, changing the enteral-feeding bag every 24 hours, checking the placement by means of gastric aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding are interventions used to provide care of the client with a PEG tube. Residual amounts should be assessed prior to each feeding, not once daily.
The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?
A. light palpation
B. deep palpation
C. percussion
D. auscultation
D
Auscultation of the client's abdomen is performed next because manual manipulation can stimulate the bowel and create false sounds heard during auscultation
A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure?
A. place the client in the left lateral position
B. monitor blood pressure, pulse and breathing every 4 hours
C. assess for signs of bleeding and hypovolemia
D. progress activity as soon as possible
C
Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy. Having the client placed in a right lateral position, not left, applies pressure at the site. Because of the increased risk for bleeding, a gradual return to normal activities over 1-2 days is desired. Monitoring vital signs at 1-2 hours intervals for 6-8 hours after the procedure is recommended to detect pneumothorax, hemothorax, or other internal bleeding.
A client with rheumatoid arthritis is prescribed piroxicam (feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis?
A. production of replacement cartilage is stimulated
B. inflammation is reduced by inhibiting prostaglandin synthesis
C. bradykinin is inhibited, thereby reducing acute and chronic pain
D. further destruction of the articular cartilage is prevented
B
NSAIDs used for treating rheumatoid arthritis inhibit the synthesis of prostaglandins and relieve associated pain, but they do not generate new cartilage. NSAIDs are not an effective treatment to inhibit bradykinin. Joint destruction is not preventable with this disease
A nurse is preparing a teaching plan for a client who is post-menopausal. Which measure is most important for the nurse to include to prevent osteoporosis?
A. bicycle for at least 3 miles every day
B. use only low fat milk products
C. take a multivitamin daily
D. perform weight resistance exercises
D
Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises is most important in the prevention of osteoporosis in post-menopausal women. Although the other answers provide common health maintenance behaviors, weight bearing exercise provides the best preventive measure in preventing calcium mobilization out of the bone
The nurse is providing instructions about log rolling to a client who returns to the post-operative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique?
A. allows the nurse to move the client freely without assistance
B. maintains correct spinal alignment to protect the surgical area
C. helps to minimize pain and anxiety
D. prevents dizziness while stabilizing the spine
B
Log-rolling technique maintains the spine in a straight superior-inferior plan that aligns the spine without movement while protecting the surgical area, which is especially important when the procedure involves bone grafts that may take several weeks for the bone to fuse.
A college student who is diagnoses with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first?
A. perform glucose measurement using a capillary blood sample
B. instill the first dose of nystatin (mycostatin) vaginally per applicator
C. cleanse perineum with warm soapy water 3 times per day
D. obtain a blood specimen for sexually transmitted disease (STDs)
B
Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms.
A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect?
A. use the smallest amount of cream necessary to numb the skin surface
B. leave the cream on the skin for 1 to 2 hours before the procedure
C. cover the skin with a gauze dressing after applying the cream
D. rub a liberal amount of cream into the skin thoroughly
B
Topical anesthetic cream, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.
The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?
A. insert a rectal tube for the passage of flatus
B. document the finding as the only action
C. assessment of the client's vital signs
D. determine the time the client last voided
D
Swelling at the surgical site in the immediate post-operative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. to provide additional data supporting bladder distention, the last time the client voided should be determined next. Documentation should be made, but the client's distended bladder requires additional intervention.
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement?
A. place petrolatum gauze dressing over the stoma
B. document the assessment
C. notify the surgeon
D. secure a colostomy pouch over the stoma
C
The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate?
A. extend arms with both legs adducted to shoulder width
B. extend the left arm laterally with the left palm upward
C. extend the arms and hold this position for 30 seconds
D. extend the arm, dorsiflex the wrist, and extend the fingers
D
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make?
A. exposure to cold environmental temperature
B. body mass index
C. skin elasticity and turgor
D. though processes and speech
A
TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperature stimulate the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.
The nurse is preparing discharge instruction for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan?
A. risk for deficient fluid volume
B. risk for infection
C. disturbed body image
D. acute pain
B
A wound healing by secondary intention is an open wound that is at risk for infection. Discomfort should be minimal 2 days after surgery, and acute pain is not the priority. Risk for deficient fluid volume requires a significant amount of wound draining, which is not evident. Although a wound may contribute to a disturbed body image, the client's distress may be minimal because the wound is not visible to others.
The nurse assess a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff?
A. wear gloves when providing personal care
B. restrict pregnant staff or visitors into the room
C. wash hands after caring for the client
D. follow contact isolation procedures
The organism Candida albicans, that causes infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.
Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire?
A. presence of carbonaceous particles in sputum
B. pulse oximetry reading of 80%
C. cherry red color to the mucous membranes
D. expiratory stridor and nasal flaring
C. cherry red color to the mucous membrane
The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induce a cherry red color of the mucous membranes in a client who experienced a burn injury during a house fire. Super heated air or smoke inhalation damage the lining of the airways which causes swelling, decreased oxygenation, and expiratory stridor. Mouth breathing during the fire allows the inhalation of soot that is seen as particles in the client's sputum.
Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?
A. full thickness burns rather than partial thickness
B. inability to distinguish sharp versus dull sensation in the extremity
C. slow capillary refill in the digits with absent distal pulse points
D. supinates extremity but unable to fully pronate the extremity
C. slow capillary refill in the digits with absent distal pulse points
A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial space. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.
Which finding are within expected parameters of a normal urinalysis for an older adult?
A. protein small
B. nitrate small
C. sugar negative
D. specific gravity 1.015
E. bilirubin negative
F. pH 6
C, D, E, F
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client?
A. impaired comfort
B. ineffective health maintenance
C. risk for injury
D. disturbed body image
A. impaired comfort
In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, and support the primary nursing diagnosis "impaired comfort"
The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract?
A. avoid consuming alcohol and caffeinated beverages
B. have intercourse or masturbate at least twice a week
C. empty the bladder completely with each voiding
D. wear a condom when having sexual intercourse
B. have intercourse or masturbate at least twice a week
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for bacteria, which can infect other areas of the GU tract. Draining the prostate regularly through intercourse or masturbation decreases the number of bacteria present and reduces the risk for further infection from stored contaminated fluids.
the nurse is providing discharge instruction to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis?
A. "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer"
B. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle"
C. "I should always use a condom because I am at increased risk for acquiring a STD"
D. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle"
D. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle
Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. the client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.
A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first?
A. notify the client's healthcare provider
B. prepare a warm enema solution for rectal instillation
C. document the finding in the client record
D. obtain a large bore needle for aspiration of the corpora cavernosa
A. notify the client's healthcare provider
Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation of the penis, causing reduction of blood flow and oxygenation to the penis, so the healthcare provider should be notified immediately.
Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer?
A. neisseria gonorrhoea
B. human papillomavirus
C. chlamydia trachomatis
D. herpes simplex virus
B. human papillomavirus
HPV is known to alter cervical epithelium cytology, which is consistent with early changes of cervical cancer. Although the others place the client at risk for exposure to HPV, these are likely to place the client at risk for PID
What is the primary nursing problem for a client with asymptomatic primary syphillis?
A. sexual dysfunction
B. acute pain
C. risk for injury
D. deficient knowledge
D. deficient knowledge
An asymptomatic client with primary syphillis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge.
The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphillis. What precaution should the nurse implement?
A. gloves should be worn during direct contact with the client's skin
B. a mask should be worn by anyone entering the client's room
C. no precautions in addition to standard precautions are necessary
D. handwashing is required before and after contact with the client
A. gloves should be worn during direct contact with the client's skin
The secondary stage of syphillis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin
During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care?
A. promotion of comfort
B. information about transmission
C. prevention of pregnancy
D. instruction in condom use
A. promotion of comfort
the initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority.
A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide?
A. "Because there is no cure for this disease, telling him is of no benefit to him or you"
B. "Even though you are angry, he should be told, so he can take precaution to prevent the spread of infection"
C. "You do not have to tell him because this is not a reportable disease"
D. "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease"
B. "Even though you are angry, he should be told, so he can take precaution to prevent the spread of infection"
Anger is a common emotional reaction when confronted with the diagnosis of an STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.
A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement?
A. prepare the client for an emergency echocardiography
B. notify the healthcare provider
C. place the client in the supine position
D. increase the IV flow rate
B. notify the healthcare provider
Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with an MI indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication.
