ATI Level 2 Practice Assessment A

A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make?

A: "Let's talk about a few ways you have dealt with stress in the past."

B: "I believe that you will regret that decision. Your family needs your support."

C: "I agree that you have to do what is best for your well-being at this time."

D: "I think you should try to put your feelings aside and focus solely on your child."

A: This statement by the nurse combines two therapeutic responses, active listening and focusing. Used together, these techniques facilitate communication by letting the parent know one's feelings are heard and taken seriously, which conveys acceptance and respect. Therefore, the parent feels the nurse validates the concerns and becomes comfortable asking the nurse sensitive questions about the child.

This statement by the nurse is a defensive response, which is nontherapeutic, because the parent's concerns are ignored. The nurse should listen to the parent with a nonjudgmental attitude to discover the reasons the parent feels coping is too difficult in this situation. The nurse should remember that listening to the parent does not imply that she agrees with the parent's actions, it simply encourages further expression of feelings.

This statement by the nurse is showing approval of the parent's actions, which is nontherapeutic. Approving insinuates that the parent's plan is the only acceptable one. Instead, the nurse should assist the parent to explore other options in an attempt to gain further insight into the parent's feelings and improve the foundation for effective interaction.

This statement by the nurse is giving a personal opinion about the parent's plan, which takes decision making away from the parent, inhibits spontaneity, and creates doubt in the parent's mind. This can cause the parent to become defensive and discourage any further communication with the nurse. The nurse should remember that the solution to a perceived problem belongs to the parent.

A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching?

A: "Maintain bone health by eating fruits, vegetables, and protein."

B: "Tamsulosin can slow the progression of bone deterioration."

C: "Walk 20 minutes two times a week to manage osteoporosis."

D: "Start to increase vitamin C and magnesium in your diet."

A: The nurse should instruct the client that the best way to maintain bone health and bone remodeling is by eating fruits, vegetables, and protein.

The nurse should instruct the client that alendronate, not tamsulosin, is often administered to slow the progression of bone deterioration.

The nurse should instruct the client to walk 30 min for three to five times a week, as this type of exercise is the most effective for osteoporosis prevention and bone remodeling.

The nurse should instruct the client to increase vitamin D and calcium in the diet to improve bone remodeling and decrease the progression of bone deterioration.

A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make?

A: "You'll need to take this medication once a day at bedtime."

B: "This medication causes adverse effects if the dosage is too high or too low."

C: "Continuing this medication therapy long-term will eventually cure your hypothyroidism."

D: "Potassium supplements can reduce the effectiveness of this medication."

B: The nurse should instruct the client that levothyroxine, in the right dosage, does not typically cause adverse effects. If the dosage is too low, the manifestations of hypothyroidism will recur. If the dosage is too high, the manifestations of hyperthyroidism will occur.

The nurse should instruct the client to take levothyroxine once a day, at least 30 to 60 min before breakfast.

The nurse should instruct the client that there is no cure for hypothyroidism. Levothyroxine will relieve the symptoms, but it will not cure an underactive thyroid condition. Therapy with thyroid hormone replacement is lifelong.

The nurse should instruct the client that calcium, magnesium, and iron supplements can reduce the effectiveness of levothyroxine. The client should take these supplements at least 4 hr after taking levothyroxine.

A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective?

A: Urine output 0.5 mL/kg/hr

B: Capillary refill 3 seconds

C: Heart rate 148/min

D: Brisk skin turgor

D: The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective.

The nurse should expect the child to have a urine output greater than 1 mL/kg/hr if fluid replacement therapy has been effective.

The nurse should expect the child to have a capillary refill of 2 seconds or less if fluid replacement therapy has been effective.

Tachycardia is a manifestation of dehydration. The nurse should expect the child to have a heart rate within the expected reference range for a 3- to 4-year-old child if fluid replacement therapy is effective.

A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take?

A: Use a gait belt and stand on the client's right side to assist with ambulation.

B: Encourage the client to use wide-grip utensils when eating with the right hand.

C: Place personal items on the bedside table close to the bed on the client's left side.

D: Remove rolled toilet paper from the holder for easier access for the client

B: The nurse should encourage the client who has hemiparesis to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating.

The nurse should stand on the client's affected side and use a gait belt for additional support when assisting a client who has hemiparesis to ambulate.

The nurse should place personal items within reach on the unaffected side to encourage independence for the client who has hemiparesis.

The nurse should provide boxed tissues in place of rolled toilet paper for the client who has hemiparesis. These are easier to use and will promote independence in toileting.

A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia?

A: Feverfew

B: Gingko

C: Valerian

D: Garlic

D. The nurse should include that garlic can help improve cholesterol levels, which then helps to reduce the buildup of plaque in the arteries. For some clients, it can also help lower blood pressure.

A client who has migraine headaches can take feverfew prophylactically to reduce the frequency of the headaches. Feverfew does not affect cholesterol levels.

A client who has peripheral artery disease or memory impairment can benefit from taking gingko. Gingko can help improve circulation throughout the body and the brain, but it does not affect cholesterol levels.

A client can take valerian to help promote sleep and reduce anxiety, but it does not affect cholesterol levels.

A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take?

A: Obtain a wound culture 30 min after initiating IV antibiotics.

B: Place a fan on the lowest setting in the client's room.

C: Apply a cooling blanket directly on the client's skin.

D: Set the temperature of the client's room to 22.2° C (72° F).

D: Set the temperature of the client's room to 22.2° C (72° F). This promotes a reduction in the client's fever without causing shivering. By combining nonpharmacological interventions with antipyretics, the nurse can reduce the client's fever.

The nurse should obtain a wound culture prior to initiating IV antibiotics. By obtaining the culture while the client has a fever and prior to antibiotics, the nurse promotes accuracy in identification of the causative micro-organism.

The nurse should avoid the use of fans in the client's room. Though a fan can decrease the environmental temperature, it promotes dispersal of pathogens in the air and can cause the client to experience shivering.

The nurse should avoid applying a cooling blanket directly on the client's skin because of the risk for injury to the skin. The nurse should place a bath blanket between the cooling blanket and the client's skin.

A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider?

A: Urine color is light pink.

B: The suprapubic area is soft to palpation.

C: The catheter tubing has multiple red clots.

D: The bowel sounds are hypoactive

C: The nurse should identify that the presence of multiple red clots in the catheter tubing or drainage that is ketchup-like are manifestations of postoperative bleeding. The nurse should notify the provider and provide hand irrigation of the bladder per provider prescription.

The nurse should report a urine color of bright red, which indicates arterial bleeding. The client is at risk for postoperative bleeding following a TURP. To manage bleeding, continuous bladder irrigation is used.

The nurse should expect the client's suprapubic area to be soft to palpation following a TURP. Assessment findings of a distinct firmness to and distention of the suprapubic area are manifestations of urinary retention.

The nurse should identify that hypoactive bowel sounds are an expected finding in a client who is postoperative following the administration of general anesthesia. The anesthetic agent, as well as any opioids administered, can slow the client's bowel motility and result in hypoactive bowel sounds for at least 24 hr.

A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care?

A: Position the affected leg flat when sitting up in bed.

B: Instruct the client to perform weight-bearing activities on the affected leg.

C: Check for paresthesia of the affected leg.

D: Apply heat to the surgical incision area of the affected leg.

C: The nurse should include in the interventions to check for paresthesia, such as a tingling sensation of the leg and foot, which can indicate manifestations of neurovascular compromise or compartment syndrome.

The nurse should position the client's affected leg on pillows to increase venous return and decrease swelling. Swelling in the surgical area can lead to manifestations of neurovascular compromise.

The nurse should instruct the client to gently move the affected leg through range-of-motion exercises, but should avoid stress on the bone that is weakened from the infection.

The nurse should apply ice around the surgical site to decrease swelling. Swelling in the surgical area can lead to manifestations of neurovascular compromise.

A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?

A: Presence of a transparent cornea

B: Presence of strabismus

C: Pinna moderately extends outward from the skull

D: Walls of peripheral aspect of auditory canal are pink

B: The nurse should recognize that the presence of strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report this finding to the provider.

The nurse should recognize that the presence of a clear or transparent cornea is an expected finding for a 2-year-old toddler. Reportable findings include opacity or the size, shape, and movement of pupils.

The nurse should recognize that the pinna extending slightly outward away from the skull is an expected finding in a 2-year-old toddler. Reportable findings include ears that are flat against the head or protrude away from the scalp. These findings indicate problems, except in newborns.

The nurse should recognize that pink walls of the external auditory canal are an expected finding for a 2-year-old toddler. The external auditory canal walls are more pigmented in a child who has dark skin. Reportable findings include foreign objects, indications of irritation, or infection.

A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching?

A: Consume five to seven servings of red meat per week.

B: Limit daily calorie intake from saturated fat to 18%.

C: Increase fiber intake to at least 30 g per day.

D: Exercise 2 days a week for at least 60 min

C: The nurse should instruct the client to increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis.

The nurse should instruct the client to decrease the intake of red meat. Red meat is high in cholesterol and saturated fat, which can worsen atherosclerosis.

The nurse should instruct the client to limit calories from saturated fat to no more than 6% of daily intake. The nurse should instruct the client to consume low-fat and nonfat foods.

The nurse should instruct the client to exercise 3 to 4 days a week for at least 40 min. The client should engage in moderate to strenuous physical exercise.

A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer?

A: Diminished peripheral pulsations in the right lower leg

B: Discoloration and edema of the right ankle

C: Atrophy of the skin and hair loss on the right leg

D: Dependent rubor in the right leg

B: The nurse should identify that manifestations of peripheral venous disease include discoloration and edema of the ankle, resulting from venous hypertension.

The nurse should identify that decreased or absent posterior tibial, and sometimes pedal pulses, are manifestations of peripheral arterial disease.

The nurse should identify that atrophy of the skin and hair loss are manifestations of peripheral arterial disease.

The nurse should identify that dependent rubor, or redness when the client lowers the extremity, is a manifestation of peripheral arterial disease.

A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching?

A: "Notify your provider if you notice small pieces of tissue in your urine."

B: "Any urinary incontinence will be permanent."

C: "Expect to see an increase in the amount of semen produced."

D: "Perform Kegel exercises several times throughout the day."

D: The nurse should instruct the client on the performance of Kegel exercises, or tightening and then relaxing the urinary sphincter, to assist the client in regaining urinary control and eliminate dribbling or the leakage of urine. The nurse should encourage the client to perform these exercises several times each day.

The nurse should instruct the client that his urine might contain small blood clots and pieces of tissue for several days following catheter removal. The nurse should encourage the client to increase fluid intake to 2 to 2.5 L daily to promote urination.

The nurse should instruct the client that dribbling small amounts of urine is an expected finding following the removal of a catheter after undergoing a TURP. The nurse should advise the client that temporary measures to keep clothing dry might be necessary, but the dribbling is temporary and will decrease when sphincter control returns.

The nurse should instruct the client that he might experience retrograde ejaculation following a TURP procedure, in which most of the semen flows into the bladder rather than being ejaculated.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.)

A: Nocturia

B: Dependent edema

C: Dyspnea

D: Hacking cough

E: Anorexia

Nocturia is correct. Left-sided heart failure causes oliguria during the day and nocturia during sleeping hours.

Dependent edema is incorrect. Dependent edema is a manifestation of right-sided heart failure.

Dyspnea is correct. Left-sided heart failure causes pulmonary manifestations, such as dyspnea, orthopnea, crackles, and wheezes.

Hacking cough is correct. Left-sided heart failure causes a hacking cough that worsens at night and eventually produces frothy sputum.

Anorexia is incorrect. Anorexia, nausea, and abdominal distention and pain are manifestations of right-sided heart failure.

A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching?

A: Drink tomato juice with the breakfast meal.

B: Suck on peppermint when having indigestion.

C: Elevate the head of the bed 10 cm (4 in) using wooden blocks.

D: Plan to finish eating at least 3 hr before bedtime.

D: The nurse should encourage the client not to eat anything at least 3 hr before bedtime to prevent reflux.

The nurse should tell the client not to drink tomato juice or any acidic beverages because acidic beverages can increase reflux.

The nurse should encourage the client not to suck on peppermint because it increases reflux.

The nurse should instruct the client to elevate the head of the bed 15.2 to 30.5 cm (6 to 12 in) by placing a foam wedge under the head of the bed to decrease reflux.

A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination?

A: "Drink at least 24 ounces of water each hour."

B: "Void as soon as you feel the urge."

C: "Expect a prescription for a diuretic."

D: "Take an antihistamine each night at bedtime."

B: The nurse should instruct a client who has BPH on measures to prevent distension of the bladder and urinary retention. Encouraging the client to void as soon as the urge develops decreases the risk of bladder distension.

The nurse should encourage adequate fluid intake; however, a client who has BPH should avoid consuming large amounts of fluid in a short period of time. Drinking large amounts of fluids at once increases the risk of bladder distension.

The nurse should instruct a client who has BPH to avoid diuretics because of the increased risk of bladder distension. For this reason, the client should also avoid alcohol and caffeine because of the diuretic effect.

The nurse should instruct a client who has BPH to avoid antihistamines and other medications, such as decongestants and anticholinergics, because these types of medications increase the risk of urinary retention.

A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect?

A: Increased deep tendon reflexes

B: Hypoactive bowel sounds

C: Decreased level of consciousness

D: Bradycardia

C: The nurse should expect a client who has hyponatremia to have cerebral edema and increased intracranial pressure as fluid moves into the cells in the brain. This can manifest as confusion, changes in level of consciousness, and seizures.

The nurse should expect a client who has hyponatremia to have manifestations of muscle weakness and diminished deep tendon reflexes.

The nurse should expect intestinal motility to increase in clients who have hyponatremia, resulting in hyperactive bowel sounds, diarrhea, and abdominal cramping.

The nurse should expect a client who has hyponatremia to have tachycardia. Bradycardia is a manifestation of hypercalcemia.

A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching?

A: "I will blow out as hard as I can before I use the peak flow meter."

B: "I will not take my controller medication if my peak flow meter scores in the yellow zone."

C: "I will base my peak flow meter score on the best of three attempts."

D: "I will go to the emergency room if my peak flow meter is in the green zone."

C: The client's peak flow rate should be based on the best of three trials of the peak flow meter. The client should record this finding and share it with the provider on the next visit.

The client should take a deep breath and then place his lips around the mouthpiece of the peak flow meter.

A yellow zone reading is an indication that asthma symptoms have increased and the client is performing at 50% to 80% of his personal best. The nurse should instruct the client to use prescribed relief medications following a reading in the yellow zone.

The peak flow meter is designed to evaluate how well asthma is being controlled. It is divided into three zones, green, yellow, and red. A reading in the green zone indicates asthma is well controlled and the client's efforts are within 80% of his personal best.

A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect?

A: Hyperreflexia

B: Fruity breath odor

C: Sweating

D: Shallow respirations

B: The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion.

The nurse should expect a child who has a blood glucose level of 250 mg/dL to have diminished reflexes. Other manifestations include lethargy, thirst, and confusion.

The nurse should expect a child who is experiencing hypoglycemia to be sweating. A child who has a blood glucose level of 250 mg/dL will have dry skin and mucus membranes.

The nurse should expect a child who is experiencing hypoglycemia to have shallow respirations. A child who has a blood glucose level of 250 mg/dL will have deep, rapid respirations.

A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect?

A: Hypoglycemia

B: Flushed skin

C: Tachycardia

D: Hypertonicity

A: The nurse should expect an infant who has hypothermia to have hypoglycemia. Other manifestations of hypothermia include apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia.

The nurse should expect a newborn who has hyperthermia to have flushed skin. The nurse should expect an infant who has hypothermia to have manifestations such as hypoglycemia, apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia.

The nurse should expect a newborn who has hyperthermia to exhibit tachycardia. The nurse should expect an infant who has hypothermia to have manifestations such as hypoglycemia, apnea, central cyanosis, hypotonia, bradycardia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia.

The nurse should expect a newborn who has hyperthermia to exhibit hypertonicity. The nurse should expect an infant who has hypothermia to have manifestations such as hypoglycemia, apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia.

A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include?

A: Self-administer 1 mg of glucagon subcutaneously.

B: Self-administer 20 units of regular insulin.

C: Drink 120 mL (4 oz) of skim milk.

D: Drink 120 mL (4 oz) of fruit juice.

D: The nurse should instruct the client to drink 120 mL (4 oz) of fruit juice, which will provide 10 to 15 g of carbohydrates to treat the hypoglycemia.

A client who has a blood glucose of 20 mg/dL and is unconscious should receive 1 mg of glucagon subcutaneously. This is an emergency measure for severe hypoglycemia and requires another person to administer the glucagon.

Insulin lowers blood glucose levels and can worsen the client's hypoglycemia, possibly to life-threatening levels.

The nurse should instruct the client to drink 240 mL (8 oz) of skim milk, which will provide 10 to 15 g of carbohydrates to treat the hypoglycemia.

A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take?

A: Teach the client how to use breathing techniques while continuing the discussion.

B: Remain with the client until manifestations subside.

C: Speak in a high-pitched louder voice to gain the client's attention.

D: Instruct the client to join another group who is practicing yoga

B: The nurse should remain with the client in a quiet place throughout the panic attack to ensure the client's safety and assist with anxiety reduction techniques.

Breathing exercises can help a client relax and decrease anxiety; however, the nurse should not instruct the client how to use breathing techniques while continuing the group discussion, because during a panic attack the client is unable to focus.

The nurse should speak in a low-pitched voice to decrease anxiety so the client does not perceive anxiety from the nurse's tone of voice.

The nurse should provide gross motor physical activities that require using a great amount of energy to help channel and release the client's tension, such as walking, punching a bag, or playing an exertional type game. During a panic attack, the client will not be able to concentrate nor relax enough to do yoga.

A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia?

A: Apply ice packs to the client's axillae, neck, groin, and chest.

B: Administer aspirin to the client

C: Initially offer the client cool, oral fluids.

D: Continue cooling measures until the client's rectal temperature is 37.2º C (99º F).

A: The nurse should recognize that treatment for heat stroke involves cooling the client's core body temperature quickly. The nurse should apply ice to the client's axillae, neck, groin, and chest while also spraying the client's body with tepid water.

The nurse should not administer aspirin to a client who has heat stroke because aspirin can increase stress on the client's kidneys due to hypovolemia and place the client at risk for vomiting and aspiration due to neurological changes.

The nurse should provide the client who has heat stroke with aggressive IV fluid replacement to treat dehydration. The client should not have anything by mouth due to the increased risk for vomiting and aspiration from neurological changes.

The nurse should stop aggressive cooling measures when the client's rectal temperature reaches 38.9º C (102º F) because continuing the cooling measures beyond that point increases the risk for hypothermia.

A nurse in a provider's office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse's intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.)

Exhibit 1: Graphic record

Oral temperature 36.9° C (98.4° F)

Pulse rate 78/min

Respiratory rate 17/min

BP 134/86 mm Hg

Oxygen saturation 95%

Exhibit 2: Diagnostic results

Hgb 15.1 g/dL

Hct 42.4%

Fasting glucose 106 mg/dL

Potassium 4.5 mEq/L

International normalized ratio (INR) 4.2

Exhibit 3: Medication administration record

Enalapril 2.5 mg PO daily

Atorvastatin 10 mg PO daily

Hydrocodone 5 mg/acetaminophen 325 mg PO q 6 hr PRN for joint pain

A: Oxygen saturation

B: Potassium level

C: ACE inhibitor therapy

D: Coagulation time

D: The nurse should report the client's coagulation time, or INR, to the provider immediately because it is above the expected reference range, which predisposes the client to intraoperative and/or postoperative hemorrhage. The nurse should expect the provider to postpone the joint arthroplasty until the client's clotting time is within the expected reference range.

The nurse should notify the provider if the client's oxygen saturation level is below 94%.

The client's potassium level is within the expected reference range; therefore, there is no need to report this to the provider.

The nurse should monitor the client for hypotension following surgery due to the adverse effects of ACE inhibitors and the use of general anesthesia. However, taking an ACE inhibitor is not a contraindication for a client who is scheduled for surgery.

A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include in the plan?

A: Direct the client to perform incentive spirometry every 2 hr.

B: Titrate oxygen to maintain the client's oxygen saturation level at 90%.

C: Teach the client how to cough up secretions.

D: Maintain the client in a low-Fowler's position

C: The nurse should instruct the client how to cough and breathe deeply to expel productive secretions and clear the airway for optimal breathing.

The nurse should instruct the client to use the incentive spirometer every hour while awake. Incentive spirometry improves gas exchange and prevents or reverses atelectasis.

The nurse should ensure oxygen saturation levels are at least 95% to prevent hypoxia. A client who has pneumonia has decreased gas exchange and might require the use of oxygen to maintain oxygen saturation levels.

The nurse should place the client in semi-Fowler's, or orthopneic position, to help facilitate air exchange and promote rest. Orthopnea is a manifestation of pneumonia. The nurse should encourage the client to change positions frequently and to breathe deeply and cough with every position change.

A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection?

A: Negative nitrites

B: RBCs < 2

C: Positive leukocyte esterase

D: Amber-colored urine

C: The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection.

The nurse should identify that negative nitrites is an expected finding and does not indicate the client has a continuing infection. Nitrite is an enzyme that is present in the urine when bacteria are present.

The nurse should identify that less than 2 RBCs is an expected finding and does not indicate the client has a continuing infection. The presence of RBC casts can be an indication of pyelonephritis.

The nurse should identify that amber-colored urine is an expected finding and does not indicate the client has a continuing infection. The color of the urine is an indication of the concentration of the urine, which can range from straw-colored to a deep amber.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider?

A: Melena stools

B: Hemoglobin 7.6 mg/dL

C: Weight gain of 1.4 kg (3 lb) in 2 weeks

D: Dyspepsia during the day

B: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the hemoglobin below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding.

Melena stools are nonurgent because they are an expected finding for a client who has a peptic ulcer that bleeds; therefore, there is another finding that is the nurse's priority.

Weight gain is nonurgent because it is an expected finding due to the manifestation of indigestion that can occur for a client who has a peptic ulcer and the urge to eat to decrease dyspepsia; therefore, there is another finding that is the nurse's priority.

Dyspepsia, or indigestion, is nonurgent because it is an expected finding that can occur for a client who has a peptic ulcer; therefore, there is another finding that is the nurse's priority.

A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record?

A: Pyrophobia

B; Agoraphobia

C: Monophobia

D: Astraphobia

B: The nurse should document that the client is experiencing agoraphobia in the client's medical record. Agoraphobia is the fear of being outside and can be debilitating and limit a client's ability to function.

The nurse should identify pyrophobia as a fear of fire. Clients who have pyrophobia experience intense fear and anxiety about fire or flames.

The nurse should identify monophobia as the fear of being alone. Clients who have monophobia experience intense fear and anxiety when alone and frequently request friends or family to be near at all times.

The nurse should identify astraphobia as the fear of electrical storms. Clients who have astraphobia experience intense fear and anxiety during storms, and avoid leaving home when a storm might occur.

A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

A: Place the child in a room equipped with a positive-pressure airflow system.

B: Place the child in a room equipped with a negative-pressure airflow system.

C: Initiate droplet precautions for the child.

D: Initiate contact precautions for the child.

C: The nurse should initiate droplet precautions for a child who has pertussis, which is spread by large droplets in the air; therefore, the nurse should wear a surgical mask within 1 m (3.3 feet) of the child.

The nurse should identify that a child who has had an allogeneic hematopoietic stem cell transplant requires a room equipped with a positive-pressure airflow system. The airflow rate must be greater than 12 exchanges per hour and filtered through a high-efficiency particulate air (HEPA) filter.

The nurse should identify that a child who has tuberculosis requires a room equipped with a negative-pressure airflow system. The door to the client's room should remain closed and the nurse must don a respirator mask before entering.

The nurse should identify that a child who has an illness that is transmitted by direct contact or contact with items in the child's environment, such as wound infections containing multidrug-resistant organisms, requires contact precautions.

A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include?

A: "Expect this medication to give your urine a greenish tinge."

B: "Do not drink alcohol while taking this medication."

C: "Take this medication with food."

D: "Take a stool softener for the duration of therapy with this medication."

B: The nurse should instruct the client that rifampin could cause liver damage. Alcohol intensifies this risk. Rifampin is contraindicated for clients who have liver disease or consume alcohol in excess.

The nurse should instruct the client that rifampin gives skin and secretions a reddish-orange color. It can also permanently stain soft contact lenses.

The nurse should instruct the client to take rifampin on an empty stomach, either 1 hr before or 2 hr after meals.

The nurse should instruct the client that rifampin might cause diarrhea. It is not necessary for the client to take a stool softener.

A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

A: Metabolic acidosis

B: Metabolic alkalosis

C: Respiratory acidosis

D: Respiratory alkalosis

B: The nurse should identify that with Cushing's disease, also known as hypercortisolism, adrenocorticotropic hormone levels are low due to hypersecretion of the adrenal cortex. This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells.

The nurse should identify that common causes of metabolic acidosis include methanol or ethanol intoxication, hypoxia, seizure activity, diarrhea, starvation, and pancreatitis.

The nurse should identify that common causes of respiratory acidosis include chest trauma, inadequate chest expansion, and alveolar-capillary block.

The nurse should identify that common causes of respiratory alkalosis include hyperventilation, gram-negative bacteremia, high altitudes, shock, aspirin toxicity, and fear.

A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan?

A: Shake the medication vial prior to drawing up the medication.

B: Withhold epoetin if hemoglobin is less than 9 g/dL.

C: Initiate contact isolation.

D: Monitor for hypertension.

D: The nurse should monitor the client's blood pressure while receiving epoetin to identify and treat hypertension. Hypertension and cardiovascular events, such as myocardial infarction and stroke, are adverse effects of epoetin.

The nurse should avoid shaking the medication vial because this can inactivate the medication.

Epoetin is an antianemic that stimulates the production of red blood cells. The nurse should plan to administer epoetin to clients who have chemotherapy-induced anemia when the hemoglobin level is less than 10 g/dL. The nurse should withhold epoetin if the client's hemoglobin level is greater than 12 g/dL.

The client who has anemia and is receiving epoetin does not require contact isolation. A client who is anemic due to chemotherapy might be neutropenic and might require a protective environment.

A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss?

A: Becomes angry when it is time to perform colostomy care

B: Touches the colostomy stoma when the bag is changed

C: Looks away as the nurse empties the colostomy bag

D: Tells others that it will be nice to have a normal bowel movement again

B: The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief.

A client who becomes angry when it is time to perform colostomy care is experiencing the anger stage of grief and has not accepted the loss.

The client looking away as the nurse empties the colostomy bag can indicate to the nurse that the client is in denial and has not accepted the loss.

The client telling others that it will be nice to have a normal bowel movement again can indicate to the nurse the client is in denial and has not accepted the loss.

A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?

A: Metabolic acidosis

B: Metabolic alkalosis

C: Respiratory acidosis

D: Respiratory alkalosis

C: With this acid-base imbalance, the client's pH is below the expected reference range, the PaCO2 is above the expected reference range, and the HCO3- is within or possibly above the expected reference range. Common causes of respiratory acidosis are respiratory depression due to anesthesia or opioid administration, airway obstruction, and inadequate chest expansion.

A client experiencing metabolic acidosis would have a pH below the expected reference range, a PaCO2 within or below the expected reference range, and an HCO3- below the expected reference range.

A client experiencing metabolic alkalosis would have a pH above the expected reference range, a PaCO2 within or above the expected reference range, and an HCO3- above the expected reference range.

A client experiencing respiratory alkalosis would have a pH above the expected reference range, a PaCO2 below the expected reference range, and an HCO3- within or possibly below the expected reference range.

A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching?

A: Average body fat for women is 15%.

B: Obesity can cause osteoporosis.

C: Morbid obesity is measured as a BMI over 40.

D: Coronary artery disease increases with a waist size of 81.28 cm (32 in).

C: The nurse should instruct the client that the expected reference range for a healthy weight is a BMI of 25 or less. A client who has a BMI of 40 or greater is considered morbidly obese.

The nurse should instruct the client that the average amount of body fat for women is 18% to 32%.

The nurse should instruct the client that obesity could place stress on knee joints and cause osteoarthritis.

The nurse should instruct the client that a waist circumference of 88.9 cm (35 in) or greater increases the risk of developing coronary artery disease.

A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider?

A: The stool is a dark green liquid with a small amount of blood.

B: The ileostomy output is 1,000 mL for the past 24 hr.

C: The stoma is purple in color.

D: The output from the NG tube has decreased over the past 24 hr

C: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply.

The presence of a small amount of blood in the client's stool is nonurgent because it is an expected finding in the initial postoperative period. The ileostomy effluent is liquid stool that is dark green in color with possible blood present; therefore, there is another finding that is the nurse's priority.

An output of 1,000 mL in 24 hr is nonurgent because this is an expected finding for a client who has a new ileostomy; therefore, there is another finding that is the nurse's priority.

A decrease in nasogastric fluid is nonurgent because it is an expected finding for a client who is 1 day postoperative following an open ileostomy placement; therefore, there is another finding that is the nurse's priority.

A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching?

A: "Obtain a pneumococcal vaccination every 2 years."

B: "Contact your provider if you have a fever that lasts 18 hours."

C: "Wash your hands when you return home from running errands."

D: "Avoid exposure to cold air by shopping inside enclosed malls."

C: The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia.

The nurse should recommend that clients who have chronic health conditions and those over the age of 65 obtain a pneumococcal vaccination. Some providers will administer a second vaccination after 5 years.

The nurse should instruct clients who have a cold or influenza to notify their provider if they have a fever lasting more than 24 hr, if manifestations last longer than 7 days, or if manifestations worsen. Addressing viral or bacterial infections in the early stages can help prevent the development of pneumonia.

The nurse should instruct clients to avoid crowded public areas, such as a shopping mall, during cold and flu season, which occurs during the winter. Being in an enclosed space with a group of people increases the risk of transmission of respiratory bacteria.

A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take?

A: Encourage the client to repeat what the nurse has said.

B: Stand to the side of the client and speak directly into the client's ear.

C: Talk to the client by speaking in a loud tone of voice.

D: Avoid the use of hand gestures and motions when speaking with the client.

A: The nurse should have the client repeat back what is discussed. The nurse should not rely on the client's nonverbal communications, such as a nod of the head, to ensure the client understands the information.

The nurse should position herself directly in front of the client. This allows the client to focus on the nurse, read the nurse's lips, and observe body language.

The nurse should avoid speaking loudly or shouting at the client. A loud voice is often projected at a higher frequency, resulting in the client having a difficult time understanding what the nurse is saying.

The nurse can use hand motions and gestures when speaking to the client to help the client better understand what the nurse is saying.

A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching?

A: "The adhesive bandages on my incision will fall off as the incision heals."

B: "I will be able to take a shower in 1 week."

C: "I will need to follow a liquid diet for the first 3 days after surgery."

D: "I can begin to resume my normal activity level in 2 weeks."

A: The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals.

The nurse should instruct the client that she can shower or bathe the day following the surgery.

The nurse should instruct the client to resume a regular diet following surgery and slowly introduce foods containing fat to determine tolerance.

The nurse should instruct the client to rest for the first 24 hr following surgery and then begin resuming normal activities. The client should be able to resume usual activities within 1 week.

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect?

A: Otitis media

B: Parotitis

C: Facial eruption

D: Lymphadenopathy

C: The nurse should identify that facial eruption, predominantly located on the cheeks, is a manifestation of erythema infectiosum. The child has a "slapped face" appearance. The eruption generally disappears after 4 days, but can reappear if the skin is traumatized or irritated by sun, heat, cold, or friction.

The nurse should identify that otitis media is a complication of scarlet fever, not a manifestation of erythema infectiosum.

The nurse should identify that parotitis, or enlarged parotid glands, is a complication of mumps, not a manifestation of erythema infectiosum.

The nurse should identify lymphadenopathy, or swollen lymph nodes, as a complication of varicella, not a manifestation of erythema infectiosum.

A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi?

A: Maintain bedrest until calculi are expelled.

B: Withhold thiazide diuretics.

C: Encourage intake of at least 3 L of fluid each day.

D: Collect all urine for 24 hr in a collection container

C: The nurse should encourage the client to consume at least 3 L of fluid each day. Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence.

The nurse should encourage the client to ambulate frequently. Ambulation promotes urinary peristalsis and elimination of the calculi in the urine.

The nurse should expect a prescription for a thiazide diuretic to promote elimination of the calculi in the urine. Thiazide diuretics cause the client to produce an increased volume of urine, which promotes elimination of the calculi.

Following treatment, a 24-hr urine collection can help diagnose the cause of the renal calculi; however, it does not promote elimination of the calculi. The nurse should also strain all of the client's urine and check for the presence of calculi. If a fragment is observed, the nurse should send the strainer to the lab for analysis.

A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect?

A: Chest pain

B: Hallucinations

C: Feels unreal

D: Follows directions

D: The nurse should expect a client who is experiencing a mild level of anxiety to be able to follow directions and focus on the nurse's instructions. Other manifestations the nurse should expect include restlessness, heightened perception, and ability to problem solve.

The nurse should expect a client who is experiencing a panic level of anxiety to experience somatic manifestations, such as chest pain, numbness, shortness of breath, and nausea.

The nurse should expect a client who is experiencing a panic level of anxiety to experience hallucinations or delusions. The client will be unable to process what is happening and might be unable to speak.

The nurse should expect a client who is experiencing a panic level of anxiety to feel that they are unreal (depersonalization) or that the world around them is unreal (derealization). The client will be unable to process what is happening and might be unable to speak.

A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority?A: Reduce environmental stimulation.

B: Protect the client from harm.

C: Administer an anxiolytic.

D: Encourage physical exercise.

B: The greatest risk to this client is injury from uncontrollable thoughts and activity; therefore, the priority intervention is to protect the client from harming himself or others by moving to a quiet environment with decreased stimulation and staying with the client.

The nurse should stay with the client and move him to a quieter setting to decrease his anxiety; however, another action is the priority.

The nurse should administer an anxiolytic to decrease the client's anxiety; however, another action is the priority.

The nurse should encourage the client to take a walk or punch a pillow to release tension and decrease anxiety; however, another action is the priority.

A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include?

A: Apply heat for the first 48 hr.

B: Wear a sling when resting in bed.

C: Elevate the wrist above heart level.

D: Use a soft-bristle toothbrush to relieve itching under the cast.

C: The nurse should instruct the client to elevate the wrist above heart level to reduce swelling and minimize pain.

The nurse should instruct the client to apply ice for the first 24 to 36 hr to reduce swelling.

The nurse should instruct the client to elevate the arm on pillows while resting in bed. The client should wear a sling when out of bed and ambulating to relieve the fatigue caused by the weight of the cast.

The nurse should instruct the client to avoid inserting any foreign objects down into the cast. Blowing cool air from a hair dryer can relieve itching. For persistent itching or burning, the client should contact the provider.

A nurse is caring for a middle adult female client who has atrial fibrillation and is taking warfarin. The nurse should recognize which of the following as an adverse effect of the medication and notify the provider?

A: Clay-colored stools

B: Increased menstrual flow

C: Overgrowth of gingival tissue

D: Dry, non-productive cough

B: The nurse should identify that warfarin is an anticoagulant used to prevent the development of thrombosis. It suppresses coagulation, which increases the risk for bleeding. The nurse should identify indications of bleeding and hemorrhage, such as increased menstrual flow, bruising, bleeding gums, and black, tarry stools, as adverse effects of warfarin therapy and notify the provider.

The nurse should identify clay-colored stools as a manifestation of gall bladder disease caused by the blockage of bilirubin in the gall bladder.

The nurse should identify overgrowth of gingival tissue as an adverse effect of phenytoin.

The nurse should identify a dry, non-productive cough as an adverse effect of ACE inhibitors.

A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care?

A: Initiate complete bed rest.

B: Massage the left lower leg three times a day.

C: Make sure the client's legs are elevated while in bed.

D: Apply cold compresses to the left lower leg every 2 hr.

C: The nurse should ensure the client elevates her legs in bed and wears antiembolic stockings to help prevent venous insufficiency.

Evidence has shown that ambulation does not increase the risk of thromboembolic complications, and it might lessen the client's anxiety about the thrombus becoming a pulmonary embolus.

Massage could dislodge the thrombus and mobilize it, thus making it a pulmonary embolus.

Warm, moist soaks, either intermittent or continuous, are more effective for treating deep-vein thrombosis than cold compresses to relieve discomfort and promote healing.

A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as a priority?

A: Determine the client's knowledge regarding gestational diabetes.

B: Explain the effects of gestational diabetes on the pregnancy and fetus with the client.

C: Discuss dietary meal plans for gestational diabetes with the client.

D: Tell the client about manifestations of hypoglycemia.

A: The first action the nurse should take when using the nursing process is to assess the client. It is important for the nurse to determine the client's knowledge level regarding the disease process. This provides the nurse with information regarding where to start with the client teaching process.

The nurse should explain the effects of gestational diabetes to encourage compliance with the treatment plan, but there is another action the nurse should take first.

The nurse should discuss the diabetic dietary meal plans to promote compliance and self-management, but there is another action the nurse should take first.

The nurse should tell the client the manifestations of hypoglycemia in order to enhance self-management and compliance, but there is another action the nurse should take first.

A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect?

A: Progressive loss of peripheral vision

B: Opacity of the lens of the client's eye

C: Impaired central vision

D: Report of seeing floating dark spots

A: The nurse should expect a client who has POAG to report a progressive loss of peripheral vision. The nurse should perform visual field testing to determine the severity of the peripheral vision loss. The nurse should also expect diagnostic assessment to indicate increased intraocular pressure.

The nurse should expect a client who has cataracts to have opacity of the lens. Other manifestations of cataracts include blurred vision and impaired perception of color.

The nurse should expect a client who has macular degeneration to have a decline in central vision. The loss is gradual and eventually all central vision is lost.

The nurse should expect a client who has an onset of retinal detachment to see floating dark spots. The client might also report that it is as if a curtain is suddenly drawn over the visual field of the affected eye.

A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion?

A: Hallucinations

B: Vomiting

C: Bradycardia

D: Seizures

B: The nurse should identify that heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F).

The nurse should identify that clients who have heat stroke, not heat exhaustion, can have manifestations of hallucinations due to elevated temperature and dehydration.

The nurse should identify that clients who have heat exhaustion can experience tachycardia and hypotension due to dehydration.

The nurse should identify that clients who have heat stroke, not heat exhaustion, can have manifestations of coma and seizures.

A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death?

A: Adolescents cope with death better than children of other ages.

B: Adolescents view funeral services as an opportunity for closure.

C: Adolescents are more concerned with the past than the present or future.

D: Adolescents often alienate themselves from their peers when grieving.

D: The nurse should identify that adolescents dealing with death often have difficulty communicating their feelings and alienate themselves from their peers and families.

The nurse should identify that adolescents have the most difficulty coping with death and dying. They are least likely to accept their own impending death or the death of others.

The nurse should identify that adolescents often view funeral services as unnecessary or barbaric and an unwarranted expense.

The nurse should identify that adolescents are focused on the present time, causing them to fear physical changes more than death itself. Adolescents often have little concern for the past or future.

A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium?

A: Ground beef

B: Collard greens

C: Cauliflower

D: Walnuts

B: The nurse should determine that collard greens are the best food source to recommend because 1 cup contains 268 mg of calcium per serving.

The nurse should recommend a different food because there is another option that contains more calcium. A 4-oz serving of ground beef contains 20 mg of calcium.

The nurse should recommend a different food because there is another option that contains more calcium. A 1-cup serving of raw cauliflower contains 24 mg of calcium.

The nurse should recommend a different food because there is another option that contains more calcium. A 1-cup serving of walnuts contains 115 mg of calcium.

A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client?

A: Leucovorin

B: Vitamin K

C: Deferoxamine

D: Protamine

D: When there are manifestations of a heparin overdose, the nurse should anticipate that the provider might prescribe protamine to inactivate the heparin. In addition, the nurse should decrease or stop the heparin therapy for a period of time and recheck the aPTT level prior to restarting the heparin. The effects of protamine will last up to 2 hr.

Leucovorin reverses the effects of overdoses of methotrexate and other folic acid antagonists, such as trimethoprim, but it does not reverse the effects of heparin.

Injecting vitamin K reverses the anticoagulation effects of warfarin, not heparin.

Deferoxamine is a chelator that reverses the effects of acute iron poisoning, not a heparin overdose.

A nurse is assessing a client who is postoperative following the placement of an ileostomy due to complication of ulcerative colitis. In which of the following areas should the nurse expect the ileostomy to be located? (You will hind hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A: Right lower abdomen superior to umbilicus.

B: Left lower abdomen even with the umbilicus.

C: Right lower abdomen inferior to umbilicus.

A is incorrect. The nurse should expect a client who is postoperative following the placement of an ascending colostomy to have an ostomy located on the right side of the abdomen, lateral to, and slightly above the umbilicus.

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching?

A: "I should feed my infant a larger amount of formula less frequently."

B: "I should feed my infant a bottle of formula within 1 hour of bedtime."

C: "I should place my infant on his side to sleep."

D: "I should add 1 teaspoon of rice cereal to my infant's formula."

D: The parent should add 1 teaspoon to 1 tablespoon of rice cereal in order to thicken the formula. This will decrease the incidence of gastric reflux.

The parent should feed the infant smaller amounts of formula more frequently throughout the day. Smaller feedings decrease the likelihood of reflux occurring.

The parent should avoid feeding the infant a bottle close to bedtime. Feeding prior to sleep increases the incidence of reflux of gastric contents.

The parent should place the infant on his back to sleep. The parent can lay the infant in the prone position for a few minutes a day while continuously observing the infant for safety.

A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication?

A: HbA1c 6.8%

B: Hct 45%

C: Creatinine 0.9 mg/dL

D: Lipase 185 units/L

D: The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting.

The nurse should recognize that a hemoglobin A1c value of 6.8% is an indication that the client's diabetes is well controlled, which is a therapeutic response to the exenatide.

The nurse should recognize that a hematocrit of 45% is within the expected reference range of 42% to 52% for men and 37% to 47% for women.

The nurse should recognize that a creatinine of 0.9 mg/dL is within the expected reference range. The nurse should monitor the client's BUN and creatinine levels because renal failure is an adverse effect of exenatide.

A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain. The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following medications should the nurse anticipate the provider will prescribe for the client?

A: Naloxone

B: Flumazenil

C: Acetylcysteine

D: Glucagon

A: The nurse should expect the provider to prescribe naloxone for the client. Naloxone is an opiate antagonist that reverses the effects of opioids, such as morphine. Naloxone reverses respiratory depression and sedation.

Flumazenil, a benzodiazepine antagonist, reverses the effects of benzodiazepines such as lorazepam and alprazolam.

Acetylcysteine, a mucolytic, reduces the risk of hepatotoxicity after an acetaminophen overdose.

Glucagon helps correct hypoglycemia resulting from too much insulin. It does not reverse the effects of morphine.

A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis?

A: Client is an adult male.

B: Client is taking atorvastatin.

C: Client is of Asian descent.

D: Client has a history of asthma.

B: The nurse should identify that increased serum cholesterol and taking cholesterol-lowering medications, such as atorvastatin, increases the client's risk of developing cholecystitis.

The nurse should identify that female clients, especially those between the ages of 20 and 60, have a greater risk than male clients of developing gallstones leading to cholecystitis.

The nurse should identify that clients who are of American Indian, Mexican-American, or Caucasian descent are at a greater risk for developing cholecystitis.

The nurse should identify that a client history of illnesses, such as Crohn's disease or diabetes mellitus, can increase a client's risk for developing cholecystitis; however, a history of respiratory illnesses, such as asthma, does not place the client at a greater risk.

A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3 24 mEq/L. Which of the following findings should the nurse expect?

A: Paresthesias

B: Bradycardia

C: Muscle flaccidity

D: Respiratory depression

A: One of the manifestations of respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias.

A client experiencing respiratory alkalosis will exhibit tachycardia.

A client experiencing respiratory alkalosis will exhibit hyperreflexia and muscle cramping and twitching.

A client experiencing respiratory alkalosis will exhibit an increase in the rate and depth of respirations.

A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching?

A: "I will avoid drinking grapefruit juice."

B: "I will chew the medication if I can't swallow it whole."

C: "I will call the doctor if I have muscle pain in my back."

D: "I will take this medication on an empty stomach."

C: Metformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication manifesting as muscle aches, sleepiness, malaise, and hyperventilation. If these manifestations develop, the client should stop taking the medication and notify the provider immediately.

Grapefruit juice can alter the effects of many medications, including lovastatin, cyclosporine, and buspirone, but it does not affect extended-release metformin.

Extended-release metformin is designed to be metabolized over a prolonged period of time. Chewing or crushing the tablets can result in excessive absorption of the medication all at once.

The client should take extended-release metformin once a day with his evening meal to help improve absorption due to the slower gastrointestinal transit time overnight.

A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range?A: The client's ECG shows inverted T waves.

B: The client's bowel sounds become hyperactive.

C: The client's hand grasp becomes stronger.

D: The client's standing systolic BP is within 30 mm Hg of her sitting systolic BP.

C: The nurse should identify that hypokalemia can cause a decrease of skeletal muscle strength. An improvement in the client's hand grasp indicates that the potassium chloride infusion is correcting this electrolyte imbalance.

The nurse should identify that hypokalemia causes several ECG changes, including inverted or flat T waves, ST-segment depression, and an increase in U waves. If the client's potassium levels normalize, the ECG will show positive T waves, a return of the ST segment to the isoelectric line, and fewer or absent U waves.

The nurse should identify that hypokalemia reduces smooth muscle contractions in the gastrointestinal tract and the client develops hypoactive bowel sounds and constipation. Bowel sounds should normalize with correction of the low potassium level, but hyperactivity indicates overcorrection and, therefore, hyperkalemia.

The nurse should identify that hypokalemia causes orthostatic hypotension. If the client's potassium levels normalize, the client should have a standing systolic BP within 20 mm Hg of the sitting systolic BP.

A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.)

A: Apply cold packs to the affected area.

B: Treat the affected area with propranolol.

C: Elevate the affected area 15.24 cm (6 in) above the heart.

D: Place a dry heating pad over the affected area.E: Administer cefazolin intermittent IV bolus

Apply cold packs to the affected area is incorrect. The nurse should apply warm, moist heat packs, not cold packs, to the affected area. Cold packs cause vasoconstriction and decrease blood flow to the affected area, resulting in a slower healing process.

Treat the affected area with propranolol is incorrect. The nurse should apply topical antibacterial agents or administer oral or IV antibiotics to treat cellulitis. Propranolol is an antihypertensive antiarrhythmic medication and is not used to treat cellulitis.

Elevate the affected area 15.24 cm (6 in) above the heart is correct. The nurse should elevate the client's lower leg 15.24 cm (6 in) above the heart to decrease swelling, prevent venous stasis, and promote healing.

Place a dry heating pad over the affected area is incorrect. The nurse should apply warm, moist heat packs, not a heating pad, to the affected area every 2 to 4 hr to decrease inflammation by increasing blood flow through vasodilation and to promote healing.

Administer cefazolin intermittent IV bolus is correct. The nurse should administer cefazolin intermittent IV bolus antibiotic to treat the infection associated with cellulitis.

The nurse in an emergency department was caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit?

A: The sibling believes the client will wake up in a few hours.

B: The sibling is curious about what will happen to the client's body.

C: The sibling will continue to treat the client as though he were still alive.

D: The sibling will alienate themselves from her family and friends.

B: The nurse should expect a 10-year-old child to be inquisitive about what happens to the body and what will occur during funeral or memorial services.

The nurse should expect a preschooler to believe that death is temporary, or a type of sleep, and that it is reversible. A 10-year-old child should have an understanding of the permanence of death.

The nurse should expect a toddler to act as though the client is still alive due to an inability to separate real life from fantasy.

The nurse should expect an adolescent client who has a terminal illness to alienate themselves from their parents and peers. This can cause the adolescent to feel alone in their struggle to accept the finality of death.

A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.)

A: Fears transmitting their disease to others

B: Personifies death as being a type of monster

C: Exhibits interest in what happens to the body following death

D: Believes death is a temporary type of sleep

E: Believes that their own thoughts can cause death

Fears transmitting their disease to others is incorrect. The nurse should expect a school-age child to have a fear of transmitting their disease to others.

Personifies death as being a type of monster is incorrect. The nurse should expect a school-age child to personify death as evil or a type of monster.

Exhibits interest in what happens to the body following death is incorrect. The nurse should expect a school-age child to be inquisitive about what happens to a body following death and to be interested in postmortem services.

Believes death is a temporary type of sleep is correct. The nurse should expect a preschooler to view death as a temporary condition, a type of sleep that is reversible.

Believes their thoughts can cause death is correct. The nurse should expect a preschooler to believe that their thoughts can cause death to occur, which can lead to feelings of guilt and shame.

A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client?

A: Apply oxygen therapy to the client.

B: Administer an anti-inflammatory medication.

C: Check the client's nail beds.

D: Initiate IV fluid therapy.

A: The first action the nurse should take when using the airway, breathing, circulation approach to caring for a client who has respiratory acidosis is to improve the client's oxygenation. When the client's airway is patent, oxygenation and ventilation are the priorities.

The nurse should administer medications the client will need to recover from respiratory acidosis. These might include anti-inflammatory, bronchodilator, and mucolytic medications; however, there is another action the nurse should take first.

The nurse should check the client's nail beds and oral membrane for the appearance of cyanosis; however, there is another action the nurse should take first.

The nurse should ensure optimal hydration to keep the client's mucous membranes moist and to facilitate the removal of pulmonary secretions; however, there is another action the nurse should take first.

A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan?

A: Assess and record the child's blood pressure every 6 to 8 hr.

B: Weigh the child once each week using the same scale.

C: Place the child in a supine position for a minimum of 4 hr each day.

D: Offer small, frequent meals based on the child's endurance level.

D: The nurse should offer small, frequent meals based on the child's endurance level. The child requires an increase in caloric intake, but often has a low energy level. The nurse should choose times for meals when the child is most rested, and make sure those meals are high in calories.

The nurse should assess and record the child's blood pressure, heart rate, and respiratory rate every 2 to 4 hr to identify changes that might indicate decreased cardiac output.

The nurse should weigh the child daily, at the same time, using the same scale. Weight gain in a child who has heart failure can indicate accumulation of fluid.

The nurse should maintain the head of the child's bed at a 30° to 45° angle at all times to support maximum chest expansion.

A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider?

A: Bruising over the right flank area

B: Blood-tinged urine

C: Urine pH 6.0

D: Painful urination

D: The nurse should instruct the client to immediately report flank or bladder pain, chills and fever, or difficulty urinating to the provider. Development of difficulty urinating, including decreased urine output or pain with urination, can mean that the client is developing an infection or can signal reoccurrence of a stone.

The nurse should instruct the client that bruising over the affected kidney following lithotripsy is expected and does not need to be reported to the provider.

The nurse should instruct the client that blood-tinged urine is a common occurrence for several days following lithotripsy and does not need to be reported to the provider.

The nurse should instruct the client to test urine pH up to three times daily and report abnormal levels to the provider. A urine pH of 6.0 is within the expected reference range and does not need to be reported to the provider. Urine that is highly alkalotic or acidic puts the client at high risk for reoccurrence of stone formation.

A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include?

A: Wash bedding, clothes, and towels in hot water in a washing machine.

B: Rinse the child's hair with vinegar three times a day.

C: Seal items that are not machine washable in plastic bags for 1 week.

D: Boil the child's combs, brushes, and hair clips for 5 min.

A: The nurse should instruct the parent to wash all cloth items the child has been in contact with in hot water and dry them on a hot setting in a clothes dryer for 20 min. This helps kill any lice or nits in these items.

The nurse should instruct the parent that research has shown that home remedies, such as treating the hair with vinegar, mayonnaise, petroleum jelly, and alcohol, are ineffective in killing nits.

The nurse should instruct the parent to seal nonwashable items that the child might have come into contact with in plastic bags for 14 days to kill any lice or nits on these items.

The nurse should instruct the parent to either soak these items in a pediculicide for 1 hr or soak them in boiling water for 10 min to kill any lice or nits in these items.

A nurse is teaching a client who has asthma about using a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching?

A: "I'll roll the canister between my palms a few times before using it."

B: "I'll take a deep breath and blow it out before I inhale the medication."

C: "I'll hold the mouthpiece 3 inches in front of my mouth before depressing the canister."

D: "I'll hold my breath for up to 5 seconds after inhaling the medication."

B: The client should take a deep breath while sitting or standing, then exhale forcefully when preparing to self-administer the inhalant medication.

After placing the canister in the holder and removing the cover on the mouthpiece, the client should shake the device vigorously five or six times or for 3 to 5 seconds.

The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) in front of his mouth before depressing the canister and releasing the inhalant medication. Alternatively, the client should insert the mouthpiece and stabilize it firmly with his lips before depressing the canister.

While the client releases the medication from the inhaler, he should tilt his head slightly backward and hold his breath for approximately 10 seconds to allow the medication to reach the smaller bronchioles.

A nurse is assessing a client who has COPD and is receiving nebulized acetylcysteine. Which of the following findings should the nurse expect if the medication has been effective?

A: Cough has been suppressed.

B: WBC count is within expected reference range.

C: Blood glucose levels are increased.

D: Mucus is thin and white in color.

D: The client who has COPD can experience manifestations of thick, tenacious secretions. White or clear mucus is an expected finding, which indicates the client is free of respiratory infection. Acetylcysteine is a mucolytic used to thin secretions and enable the client to expectorate them more easily.

A client can use dextromethorphan, an antitussive, to reduce coughing by suppressing the cough center in the medulla. A client who has COPD can use dextromethorphan to raise the cough threshold.

A client uses antibiotics, such as ciprofloxacin, to treat infections. The antibiotics will result in a decrease in WBC due to destruction of bacteria.

A client who uses corticosteroids, such as prednisone, can experience an increase in blood glucose levels. A client who has COPD can use corticosteroids to decrease inflammation.

A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect?

A: Somnolence

B: Cold intolerance

C: Exophthalmos

D: Dry, scaly skin

C: The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs.

The nurse should expect a client who has hyperthyroidism to experience insomnia. Somnolence is a common manifestation of hypothyroidism.

The nurse should expect a client who has hyperthyroidism to experience heat intolerance. Cold intolerance is a common manifestation of hypothyroidism.

The nurse should expect a client who has hyperthyroidism to exhibit warm, moist, and smooth skin. Cool, dry, scaly skin is a common manifestation of hypothyroidism.

A nurse is admitting a client who has just been diagnosed with active tuberculosis and has experienced a 5.9 kg (13 lb) weight loss during the past 3 weeks. Which of the following actions should the nurse take first?

A: Obtain a sputum sample for mycobacterial culture.

B: Administer the first dose of antimycobacterial medications.

C: Refer the client to a dietitian to plan a healthy diet.

D: Initiate airborne precautions.

D: The greatest risk is that the client can transmit tuberculosis to other individuals; therefore, the first action the nurse should take is to initiate airborne precautions for this client. The nurse should place the client in a private room with negative air pressure and at least six air exchanges per hour and use an N95 mask while caring for the client.

The nurse should obtain a sputum sample for mycobacterial culture to confirm the diagnosis; however, there is another action the nurse should take first.

The nurse should administer the prescribed antimycobacterial medications after obtaining the sputum specimen; however, there is another action the nurse should take first.

The nurse should refer the client to a dietitian to plan for a diet that promotes weight gain; however, there is another action the nurse should take first.

A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection?

A: Initiate contact precautions for this client.

B: Bathe the client with chlorhexidine wipes.

C: Administer ceftaroline to the client as a prophylactic measure.

D: Avoid using alcohol-based hand sanitizers after caring for the client

B: The nurse should bathe a client who is immunocompromised with chlorhexidine wipes to decrease the risk of contracting hospital-acquired MRSA.

The nurse should place a client who is immunocompromised in a protected environment. A client who already has MRSA should be placed on contact precautions.

The nurse should administer ceftaroline to a client who has already contracted a MRSA infection. Ceftaroline is a first-generation cephalosporin to treat MRSA.

The nurse should either use alcohol-based hand sanitizer or soap and water before and after caring for the client to decrease the risk of contracting or transmitting hospital-acquired MRSA.

A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect?

A: Circumoral tingling

B: Hypoactive reflexes

C: Fatigue

D: Anorexia

A: The nurse should identify that hypocalcemia causes paresthesias, which is circumoral numbness and tingling of the fingers, toes, and around the mouth.

The nurse should identify that hypocalcemia causes hyperactive reflexes and a positive Chvostek's sign, which is a tightening of the muscles in the face when the nurse taps the client's facial nerve.

The nurse should identify that hypercalcemia, not hypocalcemia, causes fatigue and lethargy.

The nurse should identify that hypercalcemia, not hypocalcemia, causes anorexia, nausea, vomiting, and constipation.

A nurse is teaching a male client who has hypertension about dietary guidelines to help manage his disorder. Which of the following instructions should the nurse include?

A: Reduce sodium intake to 1,500 mg/day or less.

B: Maintain a BMI of 30.

C: Add high-protein sources, such as beef and pork, to the diet.

D: Limit alcohol consumption to no more than three drinks per day.

A: The nurse should instruct the client to keep his daily sodium intake below 1,500 mg/day. Reducing sodium intake can lower both systolic and diastolic blood pressure.

The nurse should instruct the client to maintain a BMI of 25 or less to help lower systolic blood pressure. The client who has a BMI of 30 is considered obese.

The nurse should instruct the client to limit his number of servings of red meat to two or fewer per day as red meat can be high in fat and cholesterol. If the client eats red meat, it should be lean, with the fat trimmed away.

The nurse should instruct the client to reduce hypertension. Men should have no more than two drinks per day and women should have no more than one drink per day.

A nurse is providing dietary teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

A: Less than 30% of daily calories should come from fat.

B: Decrease caloric intake to less than 25 cal/kg/day.

C: Increase sodium intake.

D: Limit daily intake of foods high in carbohydrates.

A: The nurse should instruct the client to choose foods low in fat and ensure that less than 30% of her daily total caloric intake is from fat. Limiting daily fat intake will improve lipid levels.

The nurse should instruct the client to maintain a daily caloric intake of 35 cal/kg/day.

The nurse should instruct the client to consume no more than 2 to 3 g of sodium as nephrotic syndrome can cause edema.

The nurse should instruct the client to maintain carbohydrate intake to provide an adequate daily calorie count.

A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this chronic disease. Which of the following instructions should the nurse include? (Select all that apply.)

A: Avoid sun exposure.

B: Increase dairy product intake.

C: Engage in weight-bearing exercises regularly.

D: Increase phosphate intake.

E: Reduce excessive caffeine intake

Avoid sun exposure is incorrect. To help prevent osteoporosis, the client needs an adequate amount of sun exposure, which helps generate vitamin D. The client should also increase her intake of foods fortified with vitamin D, such as some breads and cereals.

Increase dairy product intake is correct. To help prevent osteoporosis, the client should increase her dietary intake of dairy products, which are a good source of calcium.

Engage in weight-bearing exercises regularly is correct. To help prevent osteoporosis, the client should increase weight-bearing exercises, such as walking, but should avoid activities that are jarring to the musculoskeletal system, such as jogging and horseback riding.

Increase phosphate intake is incorrect. To help prevent osteoporosis, the client should reduce her phosphate intake because phosphate reduces the calcium needed for bone remodeling. Carbonated beverages are a common source of phosphate.

Reduce excessive caffeine intake is correct. To help prevent osteoporosis, the client should limit her intake of caffeine and alcohol.

A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A: Call 911 and examine the amputation site.

B: Apply direct pressure with layers of dry cloth.

C: Elevate the extremity above the client's heart.

D: Find the toe and wrap it in sterile gauze in a clean cloth.

E: Place the toe in a bag and place the bag in 1 part ice and 3 parts water.

The nurse should first call 911 and examine the amputation site. Next, the nurse should apply direct pressure with layers of dry cloth to slow or stop the bleeding. Then, the nurse should elevate the affected extremity above the client's heart to slow the bleeding. Next, the nurse should find the toe and wrap it in sterile gauze or a clean cloth to decrease contamination for possible surgical reattachment. Finally, the nurse should place the wrapped toe in a bag and place the bag in 1 part ice and 3 parts water to maintain tissue integrity for possible reattachment.

A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus. Which of the following information should the nurse include in the teaching?

A: Soak feet daily to soften calluses.

B: Apply a heating pad to the feet to improve circulation.

C: Choose sandals with open toes to wear in the summer.

D: Trim toenails straight across to prevent ingrown toenails.

D: The nurse should instruct the clients to trim toenails straight across to prevent ingrown toenails that increase the risk for tissue breakdown and infection.

The nurse should instruct the clients to avoid soaking feet because it increases the risk for tissue breakdown that can lead to an infection.

The nurse should instruct the clients to avoid applying a heating pad to the feet because it increases the risk for causing a burn that can lead to tissue breakdown and infection.

The nurse should instruct the clients to avoid choosing footwear, such as sandals with open toes, that increases the risk for injuring the feet, which can lead to tissue breakdown and infection.

A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect?

A: Periorbital edema

B: Diaphoretic skin

C: Clubbing of fingers

D: Brittle hair

D: The nurse should expect a client who is experiencing malnutrition to have dry, brittle hair, muscle wasting, a depressed mood, and poor wound healing.

The nurse should expect a client who is experiencing malnutrition to have edema of the lower extremities or sacral area.

The nurse should expect a client who is experiencing malnutrition to have dry, rough skin.

The nurse should expect a client who has a chronic respiratory illness to have clubbing of the fingers.

A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis?

A: Abdominal pain triggered by spicy food

B: Abdominal pain that radiates to the right shoulder

C: Abdominal pain in the right lower quadrant

D: Abdominal pain that is continuous over several days

B: The nurse should expect a client who has cholecystitis to have abdominal pain that is episodic, typically occurring after fatty or large meals, and can radiate from the client's right upper quadrant to the right shoulder or scapula.

The nurse should expect a client who has GERD, or peptic ulcer disease, and consumes spicy foods to experience abdominal pain.

The nurse should identify that abdominal pain that eventually localizes in a client's right lower quadrant at McBurney's point is a classic manifestation of appendicitis, not cholecystitis.

The nurse should identify that a client who has cholecystitis will experience abdominal pain that is episodic and caused from obstruction of the cystic duct or calculi movement.

A nurse is assessing a client who has social phobia and reports feeling fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe?

A: Carbamazepine

B: Risperidone

C: Paroxetine

D: Quetiapine

C: Paroxetine is a selective serotonin reuptake inhibitor that is used to treat social anxiety disorder.

Carbamazepine is a mood stabilizer and anticonvulsant medication that treats bipolar disorder, seizure disorders, generalized anxiety disorder, and alcohol use disorder.

Risperidone is an antipsychotic medication that treats schizophrenia, bipolar disorder, and obsessive-compulsive disorder.

Quetiapine is an antipsychotic medication that treats schizophrenia, bipolar disorder, and generalized anxiety disorder.

A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client's ABG results are pH 7.28, PaCO2 36 mm Hg, and HCO3 14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?

A: Metabolic acidosis

B: Metabolic alkalosis

C: Respiratory acidosis

D: Respiratory alkalosis

A: With this acid-base imbalance, the client's pH is below the expected reference range, the PaCO2 is within or below the expected reference range, and the HCO3- is below the expected reference range. Diabetic ketoacidosis is a common cause of metabolic acidosis.

A client experiencing metabolic alkalosis would have a pH above the expected reference range, a PaCO2 within or above the expected reference range, and an HCO3- above the expected reference range.

A client experiencing respiratory acidosis would have a pH below the expected reference range, a PaCO2 above the expected reference range, and an HCO3- within or possibly above the expected reference range.

A client experiencing respiratory alkalosis would have a pH above the expected reference range, a PaCO2 below the expected reference range, and an HCO3- within, or possibly below the expected reference range.

A nurse is teaching an older adult client who has peripheral neuropathy about a new prescription for duloxetine. Which of the following client statements indicates an understanding of the teaching?

A: "It might take several weeks to notice an improvement in my symptoms."

B: "I will need to take this medication on an empty stomach."

C: "I should take a daily ibuprofen for generalized aches."

D: "I will need to decrease my dietary sodium intake while taking this medication."

A: The nurse should instruct the client that duloxetine can take several weeks to be effective. This medication is an antidepressant that reduces the discomfort of peripheral neuropathy.

The nurse should instruct the client to take the capsule whole without regard to food.

The nurse should instruct the client that duloxetine can impair platelet aggregation and taking a daily NSAID, such as ibuprofen, can increase the client's risk of bleeding.

The nurse should instruct the client that duloxetine can cause the adverse effect of hyponatremia. The nurse should monitor serum sodium levels and teach the client about the manifestations of hyponatremia.

A nurse is teaching a client who has a new prescription for finasteride to treat benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching?

A: "You might need to take the medication for several months before seeing any relief."

B: "This medication will cause an increase in your libido."

C: "You might experience prolonged erections while taking this medication."

D: "This medication will elevate your blood pressure."

A: The nurse should instruct the client it might take 6 to 12 months before improved urinary flow occurs. Finasteride is an androgen inhibitor that reduces the size of the prostate over time.

The nurse should instruct the client that a decrease in libido is an adverse effect of finasteride.

The nurse should instruct the client that he may experience erectile dysfunction as an adverse effect of finasteride.

The nurse should instruct the client that he might experience orthostatic hypotension as an adverse effect of finasteride. The nurse should instruct the client to change positions slowly to avoid dizziness or syncopal episodes due to hypotension.

A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

A: "I will stop taking the medication immediately if I experience nausea."

B: "I should contact my provider if I notice a pink-tinged color to my urine."

C: "I will increase my dietary intake of spinach."

D: "I will not be able to use an electric razor while I am taking this medication."

B: The nurse should instruct the client to monitor for blood in the urine. The client should report a pink-tinged urine color to the provider.

The nurse should instruct the client not to abruptly stop taking this medication. If the client needs to discontinue the medication, the provider will taper the dose gradually.

The nurse should review foods that are high in vitamin K with the client and instruct the client to maintain consistent intake of these foods. Inconsistent intake of these foods, such as increasing the intake of spinach, can result in a fluctuation of prothrombin time or INR levels.

The nurse should instruct the client to use an electric razor for shaving to reduce the risk of bleeding from a bladed razor cut.

A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH7.48, PaCO2 50 mm Hg, and HCO3 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances?

A: Metabolic alkalosis

B: Metabolic acidosis

C: Respiratory acidosis

D: Respiratory alkalosis

A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching?

A: "I will keep an eye patch in place for the first 3 days after surgery."

B: "It is okay for me to lift my 2-year-old granddaughter."

C: "I will be able run the vacuum cleaner in a day or two."

D: "It might take 4 to 6 weeks for my vision to fully improve."

D: The nurse should instruct the client that it can take up to 4 to 6 weeks for optimal recovery; however, the client can expect visual improvement immediately following surgery.

The nurse should instruct the client that the provider might prescribe wearing an eye patch at night while sleeping to prevent rubbing of the affected eye, but not continuous wear during the day.

The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting objects weighing more than 4.5 kg (10 lb).

The nurse should instruct the client to avoid vacuuming for several weeks to prevent bending at the waist and making abrupt movements. The client can engage in activities such as light housekeeping and cooking.

A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching?

A: "I should drink 1.5 liters of water daily to keep hydrated."

B: "I should make my abdomen rise with each inhalation."

C: "I should inhale through my mouth and exhale through my nose."

D: "I should limit walks to 10 minutes daily in order to conserve my energy."

B: Diaphragmatic, or abdominal, breathing consists of consciously breathing by moving the abdomen outward with each breath. Diaphragmatic breathing decreases shortness of breath by moving the diaphragm upward to promote removal of trapped air during exhalation.

The nurse should instruct the client to drink at least 2 to 3 L of water daily to remain hydrated and assist with thinning of oral secretions, which makes it easier to expel while coughing.

The nurse should instruct the client to use pursed-lip breathing in which he inhales through the nose and exhales through pursed lips. This method prolongs the exhalation phase and removes air trapped in the airways.

The nurse should instruct the client who has COPD to practice exercise training at least 20 min daily indoors or outdoors. This can be done by walking until dyspnea or other manifestations occur, resting 5 min, and then walking again until a total of 20 total min is completed.

A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client.

There are three tabs that contain separate categories of data.)

Exhibit 1: Provider prescriptionsScheduled medications:Administer TPN 2,000 mL bag IV continuously at 80 mL/hrPRN Medications:Acetaminophen 500 mg PO every 6 hr PRN painRegular insulin 3 units SQ for blood sugars greater than 200 mg/dL; if greater than 300 mg/dL, notify providerCheck client's blood sugar every 4 hr

Exhibit 2: Graphic recordBP 120/68 mm HgPulse 74/minRespiratory rate 20/minTemp 37.6° C (99.7° F)

Exhibit 3: Diagnostic resultsSodium 140 mEq/dLPotassium 4.2 mEq/dLBlood glucose 238 mg/dL

A: Stop the client's infusion immediately.

B: Notify the provider about the client's blood pressure.

C: Clarify the dose of acetaminophen with the provider.

D: Administer the prescribed regular insulin

D: The nurse should administer 3 units of regular insulin to the client for blood glucose greater than 200 mg/dL.

The nurse should not stop the infusion. This can place the client at risk for hypoglycemia and electrolyte imbalance.

The client's blood pressure is within the expected reference range, which is 120/80 mm Hg.

The dose of acetaminophen for an adult is 325 to 650 mg every 6 hr, not to exceed 3 g within 24 hr.

A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect?

A: Flat anterior fontanel

B: Capillary refill 2 seconds

C: 5% weight loss

D: Absence of tears

D: The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria.

The nurse should expect an infant who has mild dehydration to have a flat anterior fontanel. Manifestations of severe dehydration include a sunken anterior fontanel, parched mucus membranes, sunken eyeballs, and tachycardia.

The nurse should expect an infant who has moderate dehydration to have a capillary refill of 2 to 4 seconds. Manifestations of severe dehydration include capillary refill time of greater than 4 seconds, parched mucus membranes, sunken eyeballs, and tachycardia.

The nurse should expect an infant who has mild dehydration to have a weight loss of 3% to 5%. Manifestations of severe dehydration include a weight loss of greater than 10%, parched mucus membranes, sunken eyeballs, and tachycardia.

A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching?

A: Avoid activities that increase the respiratory rate.

B: Use pursed-lip breathing when feeling short of breath.

C: Consume a diet high in carbohydrates for increased energy.

D: Limit fluid intake to 1.5 L daily

B: The nurse should instruct the client how to use diaphragmatic and pursed-lip breathing to control breathing when feeling dyspneic.

The nurse should instruct the client to exercise until shortness of breath occurs, rest for a period of time, and then resume the exercise until completing a total of 20 min of exercise. The client can increase exercise time as tolerated. Exercise is beneficial for the client who has COPD, as it improves respiratory function and endurance. Various types of exercises are acceptable, such as walking.

The nurse should recommend the client consume a diet that is high in calories and protein. Clients who have COPD are at risk for undernutrition and protein calorie malnutrition because of the increased metabolic needs involved with breathing, early satiety, and restricted food intake due to dyspnea. The client should drink between meals and meals should consist of four to six small meals daily.

The nurse should encourage the client to consume 2 to 3 L of fluid daily to thin the secretions and enhance the ability to expectorate secretions. Clients who have COPD produce thick, tenacious secretions, which compromise the ability to breathe effectively and to cough up the secretions.

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following information should the nurse include in the teaching?

A: "If you miss a dose, you should take two doses the next morning."

B: "You should stop taking this medication immediately if you experience depression."

C: "You might experience an increased sensitivity to heat while taking this medication."

D: "You should contact your provider if your pulse rate drops below 60 per minute."

D: The nurse should teach the client how to monitor his pulse rate and further instruct the client to withhold the medication and notify his provider if his pulse rate drops below 60/min.

The nurse should instruct the client that if he misses a dose, he should take it as soon as he remembers up to 8 hr prior to the next dose. The client should not take two tablets at once.

The nurse should instruct the client to contact his provider to discuss the adverse effect of depression; however, the client should not abruptly stop taking the medication because this can lead to life-threatening hypertension.

The nurse should instruct the client that he might experience increased sensitivity to cold while taking this medication.

A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis?

A: Abdominal distention

B: Bradycardia

C: Hyperactive bowel sounds

D: Slow, deep breathing

A: The nurse should identify that peritonitis is an inflammation of the lining of the abdominal wall. This inflammation, along with the ileus that develops, causes abdominal distention; therefore, the nurse should identify this as a manifestation of peritonitis.

The nurse should identify that tachycardia, rather than bradycardia, is a manifestation of appendicitis as well as peritonitis.

The nurse should identify hypoactive, rather than hyperactive bowel sounds, as a manifestation of peritonitis.

The nurse should identify rapid, shallow breathing, rather than slow, deep breathing, as a manifestation of peritonitis.

A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect?

A: Hypophosphatemia

B: Hypochloremia

C: Hypermagnesemia

D: Hypernatremia

C: The nurse should identify that frequent ingestion of antacids and laxatives that contain magnesium can cause hypermagnesemia. Manifestations include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contractions, ECG changes, lethargy, and drowsiness that can progress to coma.

The nurse should identify that hypophosphatemia can cause muscle weakness, as well as seizures, nystagmus, confusion, chest and bone pain, and paresthesias.

The nurse should identify that hypochloremia can cause dysrhythmias, as well as irritability, agitation, hyperactive deep tendon reflexes, bradypnea, and seizures.

The nurse should identify that hypernatremia can cause lethargy, as well as fever, thirst, restlessness, hyperreflexia, nausea, vomiting, tachycardia, and hypertension.

A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching?

A: "I should wipe off the hearing aid each day with an alcohol wipe."

B: "I will change the battery in the hearing aid when it makes a whistling sound."

C: "I will make sure the hearing aid is off before inserting it in my ear."

D: "I should start wearing the hearing aid for at least 1 hour at a time."

C: The client should turn down the volume of the hearing aid and turn it off before inserting it in the ear. This ensures that the client is not exposed to any uncomfortably loud noise when it is inserted. Once it is in place, the client should turn the hearing aid on and adjust the volume to a comfortable level.

The client should avoid the use of alcohol when cleaning the hearing aid because it can cause damage to the device. The nurse should instruct the client to use soap and water, rinse, and dry well.

The client should plan to change the battery each week; however, the nurse should instruct the client to turn the volume down when there is a whistling sound. A whistling sound can indicate incorrect placement of the hearing aid or excess earwax in the client's ear.

The client should start wearing a newly prescribed hearing aid for 15 to 20 min at a time. As the client gets used to the hearing aid, the time can gradually be increased to 10 to 12 hr.

A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication that the client might have a small-bowel obstruction?

A: Peripheral edema

B: Minimal vomiting

C: Intermittent cramping in the lower abdomen

D: Visible peristaltic waves in the upper abdomen

D: The nurse should identify that visible peristaltic waves in the upper and middle abdomen are a manifestation of a small-bowel obstruction. The client might also have abdominal discomfort or pain.

The nurse should identify that a small-bowel obstruction causes dehydration, not edema, with intense thirst and dry mucous membranes.

The nurse should identify that nausea and profuse vomiting are manifestations of a small-bowel obstruction.

The nurse should identify that cramping in the lower abdomen is a manifestation of a large-bowel obstruction.

A nurse is discussing lactose-free foods with a client who is experiencing malabsorption due to lactose intolerance. Which of the following foods should the nurse recommend?

A: Sour cream

B: Soy milk

C: Ice cream

D: Plain yogurt

B: The nurse should instruct the client to consume foods that are lactose-free and are nondairy products. Acceptable foods include soy milk, almond milk, and soy cheeses.

The nurse should instruct the client to avoid consuming foods that contain lactose, including dairy products. Sour cream is made with milk and is not recommended for a client who has lactose intolerance.

The nurse should instruct the client to avoid consuming foods that contain lactose, including dairy products. Ice cream is made with milk and is not recommended for a client who has lactose intolerance.

The nurse should instruct the client to avoid consuming foods that contain lactose, including dairy products. Yogurt is made with milk and is not recommended for a client who has lactose intolerance.

A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection?

A: "I will apply the lotion once a day for 1 week."

B: "I will rub in the lotion thoroughly from my face to my toes."

C: "I will wash the lotion off 12 hours after I apply it."

D: "I should avoid bathing for 6 hours prior to applying the lotion."

C: The nurse should instruct the client to apply the lotion and leave it in place for 8 to 12 hr and then remove it by washing it off.

The nurse should instruct the client to apply the lotion once. If live mites are still present, the nurse should instruct the client to reapply a second application one week following the first application.

The nurse should instruct the client to apply approximately 60 mL of the lotion in a thin film covering the body from the neck down.

The nurse should instruct the client to bathe with soap and water, dry the skin well, and allow it to cool prior to applying the lotion.

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect?

A: Numbness of hands

B: Gingival hyperplasia

C: Clay-colored stools

D: Carotid bruits

A: The nurse should identify that pernicious anemia is caused by a lack of vitamin B12 and can have neurologic manifestations, such as numbness and tingling of the client's extremities. Other manifestations include pale or yellow-tinged skin, glossitis, weight loss, fatigue, and problems with balance.

The nurse should identify that gingival hyperplasia is an adverse effect associated with phenytoin. It is not associated with pernicious anemia.

The nurse should identify that clay-colored stools are a manifestation of the blockage of bile within the biliary system. They are not associated with pernicious anemia.

The nurse should identify that carotid bruits are associated with turbulent blood flow and are the result of atherosclerosis. They are not associated with pernicious anemia.

A nurse is assessing a client who has developed type 1 herpes simplex virus. Which of the following images should the nurse identify as this type of viral infection?

A: A red tongue with white streaks.

B: A brown and red rash on the left middle abdomen.

C: Lips with white and red sores.

D: Toes with a crusty rash.

C: Herpes simplex virus infection is a common viral infection in adults. The nurse should identify that this image indicates the type 1 herpes simplex viral infection because the infection causes a recurring cold sore.

The nurse should identify that this image (A) indicates candidiasis, a fungal infection that can result in oral lesions or thrush on the oral mucous membrane.

The nurse should identify that this image (B) indicates herpes zoster or shingles. This infection occurs in clients who have previously had chickenpox when the varicella-zoster virus is reactivated.

The nurse should identify that this image (D) indicates a dermatophyte fungal infection, also referred to as tinea pedis, or athlete's foot.