212 COMPRE

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that

a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs

C. Informal teaching is individualized one on one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

A patient expresses a strong interest in returning to their work, family, and hobbies after having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style?

a. field
b. biological
c. cognitive
d. sociologic

C. Cognitive theorists believe that attention, relevance, confidence, and satisfaction (ARCS) are the conditions that, when integrated, motivate someone to learn. Field theorists place significance on how achievement, power, the need for affiliation, and avoidance motives influence individual behavior. Sociologic theories are not involved in motivation.

The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all that apply)

a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic

C, D, E, F

clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.

Which statement made by a nurse represents the need for further education regarding pain management in older adult clients?

a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much

D

There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain.

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse?

a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink

C

The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment

The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first?

a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion

D

Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.

A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client?

a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income

D

Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with

a. prolonged stress response and a cascade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruction

A

Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response.

Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
d. Measuring intake and output every four hours

A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

Which client is at greatest risk for dehydration?

a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid

C

Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration

A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia?

a. client with type 2 diabetes taking an oral anti-diabetic agent
b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
d. client taking non-steroidal anti-inflammatory drugs daily

B

Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.

An older adult client presents with signs and symptoms related to dig toxicity. Which age related change may have contributed to this problem?

a. decreased renal blood flow
b. increased gastrointestinal motility
c. decreased ratio of adipose tissue to lean body mass
d. increased total body water

A

Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to dig toxicity.

A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition?

a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
d. I will weigh myself each morning before I eat or drink.

D

Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority?

a. assess the client's respiratory rate, rhythm, and depth
b. document findings and monitor the client
c. measure the client's pulse and blood pressure
d. call the health care provider

A

In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.

The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient?

a. 3
b. 1
c. 1 1/2
d. 2 1/5

C

60/40 (desired/have)

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective?

a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
d. slices of ham and cheese on whole grain crackers

C

Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium.

When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain?

a. inability to concentrate
b. expressed hopelessness
c. psychosocial withdrawal
d. anger and hostility

A

The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first?

A) Has had diabetes mellitus for 12 years
B) Had abdominal surgery and has a nasogastric tube
C) Just received 3 units of packed red blood cells
D) Uses sodium-containing antacids frequently

C

Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel?

A) Assess level of consciousness.
B) Evaluate the pulse oximetry reading.
C) Assist the client with meals.
D) Complete the nursing care plan.

C

The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include:

A) adherence.
B) developmental level.
C) motivation.
D) technology.

D

The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation?
A) Temperature extremes
B) Occupational exposure
C) Impaired cognition
D) Physical agility

D

Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

An older adult client is in physical restraints. Which intervention by the nurse is the priority?

A) Assess the client hourly while keeping the restraints in place.
B) Assess the client once each shift, releasing the restraints for feeding.
C) Assess the client twice each shift while keeping the restraints in place.
D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.

D

The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.

The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first?

A) Administer blood pressure medication.
B) Administer a drug to lower the heart rate.
C) Continue to assess for possible causes of elevated vital signs.
D) Assess whether the client needs anti-arthritis medication.

C

Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out.

The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem?

A) Middle-aged woman with a fractured arm
B) Client with expressive aphasia
C) Younger adult with metastatic cancer
D) Client who has undergone an appendectomy

B

Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.

Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting?

A) Cutaneous skin stimulation
B) Imagery
C) Radiofrequency ablation
D) Hypnosis

B

Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli.

What interrelated constructs facilitate a nurse to become culturally competent?

A) Cultural desire, self-awareness, cultural knowledge, and cultural skill
B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity
C) Cultural desire, self-awareness, cultural knowledge, and cultural identity
D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge

A

The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

The emphasis on understanding cultural influence on health care is important because of:

A) disability entitlements.
B) HIPAA requirements.
C) litigious society.
D) increasing global diversity.

D

Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety.
Litigious society refers to excessively ready to go to law or initiate a lawsuit.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now?

A) Examine sacral area and patient's heels for skin breakdown due to potential edema.
B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures.
C) Institute fall precautions due to potential postural hypotension and weak leg muscles.
D) Raise bed side rails due to potential decreased level of consciousness and confusion.

C

Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia?

A) Client taking digoxin (Lanoxin)
B) Client who is NPO receiving intravenous D5W
C) Client taking ibuprofen (Motrin)
D) Client taking a sulfonamide antibiotic

B

D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.

The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take?

A) Assist with intubation.
B) Monitor pain level.
C) Administer oxygen.
D) Administer naloxone (Narcan).

D

A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.

Which action does the nurse teach a client to reduce the risk for dehydration?

A) Avoiding the use of glycerin suppositories to manage constipation
B) Maintaining a daily oral intake approximately equal to daily fluid loss
C) Restricting sodium intake to no greater than 4 g/day
D) Maintaining an oral intake of at least 1500 mL/day

B

Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition?

A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L

A

Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n)
A) rectal thermometer.
B) tympanic membrane sensor.
C) temporal thermometer scan.
D) oral thermometer.

A

The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST?

A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids

B

Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective?

A) Performing range-of-motion exercises on the client three times each day
B) Assessing the client's respirations when administering opioids
C) Delegating to the nursing assistant to give the client a complete bath daily
D) Ensuring that the client is eating 100% of the meals served to him or her

B

It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety.

What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases?

A) Requesting that a family member remain with the client to assist in ambulation
B) Keeping all four siderails up while the client is in bed
C) Placing the client in restraints to prevent movement without assistance
D) Providing assistance to the client in getting out of the bed or chair

D

Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.

The nurse is caring for four clients. Which client assessment is the most indicative of having pain?

A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
D) Postoperative client with a neck incision

B

At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.

The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care?

A) Prescribe aspirin for a client who presents with an acute myocardial infarction
B) Insert a central line to give intravenous fluid to a dehydrated client.
C) Use sterile technique when changing dressings on a new surgical site.
D) Intubate a client whose oxygen saturation is 92%.

C

The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.

Which is most indicative of pain in an older client who is confused? (Select all that apply).

A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
F) Restlessness

A,C,E,F

No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is:

A) large for gestational age.
B) well nourished.
C) born at term.
D) low birth weight.

D

Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability?

A) Healthy individual, college educated, travels frequently, can balance a checkbook
B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of family and house
D) Healthy individual, works outside the home, uses a cane, well groomed

C

Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?

A) Documenting all changes observed in the client and maintaining a postoperative flow sheet
B) Monitoring the client for changes in postoperative status such as wound infection
C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic
D) Notifying the physician of the client's increase in restlessness after medication change

C

The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team.

An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.)

A) Morphine (Durmorph)
B) Meperidine (Demerol)
C) Propoxyphene (Darvocet)
D) Methadone (Dolophine)
E) Codeine

B,C,D,E

Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted.

An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off?

A) Situation
B) Recommendation
C) Background
D) Assessment

B

The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment.

Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of:

A) mixed pain syndrome.
B) chronic pain.
C) neuropathic pain.
D) nociceptive pain.

D

Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST?

A) Obtaining a fan from central supply for the client's room
B) Monitoring the client's temperature more often than ordered
C) Sponging the client while monitoring for shivering
D) Apply cool packs to the client's axillae and groin

D

The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate.

A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal?

A) The patient will demonstrate coping skills needed to manage hypertension.
B) The patient will verbalize the side effects of treatment.
C) The patient will select the type of learning materials they prefer.
D) The patient will verbalize an understanding of the importance of following the regimen.

C

Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient.

When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family.

A) development.
B) function.
C) structure.
D) political views.

D

An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.

The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action?

A) Administering oxygen by nasal cannula
B) Documenting the findings and continuing to monitor
C) Arousing the client by calling his or her name
D) Administering naloxone (Narcan) IV push

C

Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required.

The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient?

A) 8 mL
B) 7.5 mL
C) 7 mL
D) 5.5 mL

B

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?

A) KCl 20 mEq PO two times per day
B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr
C) Oxygen via face mask at 8 L/min
D) Furosemide (Lasix) 20 mg PO now

B

A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

The priority nursing intervention for a patient suspected to be hypothermic would be to:

A) hydrate with intravenous (IV) fluids.
B) remove wet clothes.
C) assess vital signs.
D) provide a warm blanket.

B

The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates:

A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.

B

With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

Why does the nurse always ask the client his or her pain level after taking routine vital signs?

A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate

B

Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management.

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate?

A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.

D

Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse?

A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal

C

A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is removed. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider.

Which finding puts a client at greatest risk for wound infection?

A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin

C

A compromised immune system puts a client at greatest risk for infection. Although all the other options might increase the client's susceptibility, the one with the greatest potential impact is being immune compromised.

The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestations does the nurse expect to see?

A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance

A

Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS.

The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment?

A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol.

B

A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided.

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention?

A) Completing all nursing care in the evening when the patient is more rested
B) Completing all nursing care in the morning so the patient can rest the remainder of the day
C) Limiting visitors, thus promoting the maximal amount of hours for sleep
D) Prioritization and administration of nursing care throughout the day

D

Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury?

A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror."
C) "Wear white socks instead of colored socks."
D) "Rotate your insulin injection sites."

A

Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

Which client does the nurse assess to be at greatest risk for pressure ulcer development?

A) Client who requires assistance with ambulation
B) Incontinent client with limited mobility
C) Client with hypertension on multiple medications
D) Client who has pneumonia

B

Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if he or she does not move about much, but having two risk factors makes the last option the person at highest risk.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to:

A) bathe and dry the skin vigorously to stimulate circulation.
B) limit intake of fluid and offer frequent snacks.
C) turn the patient at least every 2 hours.
D) keep the head of the bed elevated 30 degrees.

C

The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication?

A) "Glucovance is more effective than glyburide and metformin."
B) "Your diabetes is improving and you now need only one drug."
C) "Glucovance contains a combination of glyburide and metformin."
D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents."

C

Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin?

A) 4 PM
B) 11 PM
C) 8 AM
D) 8 PM

A

NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client?

A) Teach the client to touch and use both sides of the body.
B) Apply sequential compression stockings.
C) Instruct the client to turn the head from side to side.
D) Position the client with the unaffected side down.

B

To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility.

The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment?

A) Place the client in high Fowler's position.
B) Verbalize the placement of food on the client's plate.
C) Order a clear liquid diet for the client.
D) Turn the client's plate around halfway through the meal.

A

Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids.

Which statement indicates that the client needs more teaching about mucositis?

A) "I will use a soft-bristled toothbrush to prevent trauma."
B) "I will rinse my mouth with water after every meal."
C) "I should use an alcohol-based mouth rinse to kill bacteria."
D) "I cannot use floss because it may irritate my gums."

C

Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis.

A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client?

A) "You may experience an irregular heartbeat while on the drug."
B) "Watch for blood in your urine while taking this drug."
C) "Use a second form of birth control while on the drug."
D) "You will experience increased menstrual bleeding while on this drug."

C

The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination durg therapy based on "best practice" for controlling hypertension. Which drugs does the nurse include in the teaching plan? SELECT ALL THAT APPLY!!!

A) NSAID's
B) Aspirin
C) Aldosterone antagonists
D) ACE Inhibitors or ARB's
E) Central alpha Agonists
F) Beta Blockers
G) Diuretics

B,C,D,F,G

The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client?

A) Turn on the television to a 24-hour news station.
B) Provide auditory and visual stimulation simultaneously.
C) Ask the family to bring in pictures familiar to the client.
D) Maintain a calm and quite environment by minimizing visitors.

C

For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted, and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving?

A) Creatinine has dropped from 1.9 to 0.5 mg/dL.
B) Blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL.
C) Prealbumin level has risen from 9 to 13 mg/dL.
D) Sodium has risen from 130 to 144 mg/dL.

C

The prealbumin level is a good measure of nutritional status because its half-life is only 2 days, so it reflects current nutritional status. The client's prealbumin level is rising and almost normal, indicating that the client's nutritional status is improving. The other laboratory values are more reflective of fluid balance and kidney function.

When conducting a health history assessment, the nurse would want to know what important information about the patient's elimination status? (Select all that apply.)

A) Time of day patient defecates
B) Patient's preferences for toileting
C) List of medications taken by patient
D) Recent changes in elimination patterns
E) Changes in color, consistency, or odor of stool or urine
F) Discomfort or pain with elimination

C,D,E,F

Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patient's preferences for toileting. They are personal preferences and do not affect elimination.

A confused client is hospitalized for possible pneumonia and is admitted from the emergency department with an indwelling catheter in place. During interdisciplinary rounds the following day, what question by the nurse takes priority?

A) "Can we discontinue the in-dwelling catheter?"
B) "Will the client be able to return home?"
C) "Should we get another chest x-ray today?"
D) "Do you want daily weights on this client?"

A

An in-dwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?

A) Agraphia
B) Aphasia
C) Impaired olfaction
D) Impaired proprioception

D

A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write.

A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action?

A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia.

C
Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? SELECT ALL THAT APPLY!!

A) check the residual volume every 4-6 hours
B) use clean technique when changing the feeding system
C) keep the head of the beg elevated at least 30 degrees
D) change the feeding bag & tubing every 12 hours
E) allow closed system containers to hang for 24 hours

A,B,C,E

A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm3, prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm3. Which action by the nurse is most appropriate?

A) Request a dietary consult.
B) Assess the client's vital signs.
C) Document the findings.
D) Place the client in isolation.

A

Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The albumin and lymphocyte counts given are normal. The white blood cell count is not directly related to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional status than is the albumin count. This puts the client at risk for impaired wound healing, so the nurse should request a dietary consult.

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion

A) is a normal function of the body, and I don't have to be concerned about it."
B) varies as a person ages, so I would expect changes in the body."
C) is monitored by the physician, and I just follow orders."
D) is monitored by vital signs and capillary refill."

D

The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

A) No complaints of sexual dysfunction occur.
B) Pedal edema is not present in the lower legs.
C) No indication of renal impairment is present.
D) The blood pressure reading is 148/94 mm Hg.

C

One expected outcome for a client with hypertension is for the client to have no evidence of target organ damage, such as renal or heart disease, that can occur with poorly managed hypertension. Development of pedal edema is not directly related to the management of hypertension. Side effects of some hypertensive agents may interfere with sexual function, but this does not relate to the effectiveness of treatment for hypertension. The blood pressure reading is too high to demonstrate effective management.

What statement indicates that the client understands teaching about neutropenia?

A) "I will call my doctor if I have an increase in temperature."
B) "My grandchildren may get an infection from me."
C) "I need to use a soft toothbrush."
D) "I have to wear a mask at all times."

A

Bone marrow suppression leads to neutropenia and increases the client's risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.

A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority?

A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula.

C

The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful.

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site?

A) Apply a cold compress.
B) Discontinue the infusion.
C) Slow the rate of infusion.
D) Check for a blood return.

B

Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued.

which statement about a patient with a tube feeding indicates best practice for patient safety & quality care?

A) if the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a 50 mL piston syringe
B) when administering medications, use cold water to dissolve the drug before administering it
C) use cranberry juice to flush the tube if it is clogged
D) administer drugs down the feeding tube without flushing first, but flush the feeding tube after the drug is given

A

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action?

A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy.

C

A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing.

After initial placement of NG tubes is confirmed, how often must placement be checked? SELECT ALL THAT APPLY?

A) before medication administration
B) it is not necessary to recheck placement
C) every 4-8 hours during feeding
D) before intermittent feeding
E) according to facility policy

A,C,E

The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse?

A) Start the tube feeding as ordered and check the residual in 30 minutes.
B) Inject air into the nasogastric tube while auscultating the client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate fluid again.
D) Obtain orders for a chest x-ray to confirm placement before starting the feeding.

D

The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees.

A client has a urinary tract infection. Which assessment by the nurse is most helpful?

A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries

C

Clients who are severely immune compromised or who have diabetes mellitus are more prone to fungal urinary tract infection. The nurse should assess for these factors. A physical examination and a post-void residual may be needed, but not until further information is obtained. Travel to foreign countries probably would not be as important, because even if exposed, the client needs some degree of immune compromise to develop a fungal urinary tract infection.

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl?

A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP."
B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."
C) "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel."
D) "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity."

C

The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.

The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger?

A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.
D) The client's thyroxine (T4) level is 8 mcg/dL.

B

Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain.

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.)

A) Use a rubber ring to decrease sacral pressure when up in the chair.
B) Place a small pillow between bony surfaces.
C) Keep the heels off the bed surfaces.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Elevate the head of the bed to 45 degrees.
G) Limit fluids and proteins in the diet.

B,C,D

A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer?

A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin)

A

The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke.

A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention?

A) Place the client in Trendelenburg position to facilitate blood flow to the heart.
B) Take the client's apical pulse for 1 full minute before drug administration.
C) Instruct the client to drink 3 L of fluid daily when taking this medication.
D) Educate the client to sit on the side of the bed for a few minutes before rising.

D

Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension-induced falls. No indication is known for assessment of the apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg position is not indicated. In case of a precipitous drop in blood pressure, a modified Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in this situation.

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client?

A) New-onset confusion
B) Repeated syncope
C) Abdominal distention
D) Spontaneous ecchymosis

D

Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response?

A) "I am preventing the spread of infection from you to me or any other client here."
B) "The clothing protects me from accidentally absorbing these drugs."
C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask."
D) "These coverings protect you from getting an infection from me."

B

Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.

The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be:

A) change in level of consciousness.
B) unequal pupil size.
C) loss of primitive reflexes.
D) inability to focus visually.

A

A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS.

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?

A) "Even if I feel completely well, I should take the medication until it is gone."
B) "When my urine no longer burns, I will no longer need to take the antibiotics."
C) "If my urine becomes lighter and clearer, I can stop taking my medicine."
D) "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."

A

Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements?

A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein.

C

A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.

During assessment of a client with a 15-year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first?

A) Notify the health care provider.
B) Document the finding in the client's chart.
C) Examine the client's feet for signs of injury.
D) Test sensory perception in the client's hands.

C

Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

Which nursing intervention best assists a bedridden client to keep skin intact?

A) Use a lift sheet to move the client in bed.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Apply talcum powder to the perineal area.

A

Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area.