Fundamentals
A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hour night shift
90 ML
A nurse is checking laboratory values to determine if a client who has diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination?
Glycosylated hemoglobin levels
Checking glycosylated hemoglobin levels (HbA1c) is an accurate method to determine if the client is routinely compliant. Glycosylated hemoglobin refers to hemoglobin that is connected to glucose. Since the lifespan of an RBC is 4 months, this value will not be affected by recent changes in the client’s diet or medications.
A home health nurse is collecting data from a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching?
"I plan to use a walker to help me get around."
The client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement.
Incorrect Answers:
A. A blood thinner such as warfarin is typically prescribed to a client following joint surgery to prevent the development of a deep-vein thrombosis (DVT). The client should continue taking this medication until able to ambulate again and the provider decides it is no longer needed.
B. The nurse should instruct the client that a pillow should not be placed under the knee since this can promote a contracture of the knee joint, making it difficult to achieve full extension.
D. A CPM machine will be continued for a client who is going home following a total knee replacement. A CPM machine is used to increase the range of motion of the knee following surgery, and the client should continue using it at home until physical therapy has been discontinued by the provider.
A nurse in the PACU is collecting data from a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify that these findings are manifestations of which of the following complications?
Respiratory obstruction
intercostal retractions and a high-pitched inspiratory noise (stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.
Incorrect Answers:
A. The nurse should identify that manifestations of pulmonary edema can include tachycardia, crackles heard in the lungs, and frothy, pink sputum.
B. The nurse should identify that manifestations of a tension pneumothorax can include tracheal deviation, distended neck veins, and the absence of breath sounds on a side.
C. The nurse should identify that manifestations of a flail chest can include paradoxical chest movement, dyspnea, and cyanosis.
A nurse is teaching a client about a new prescription for extended-release oxycodone for pain management. Which of the following statements should the nurse include in the teaching?
"Swallow this medication whole."
The nurse should tell the client that extended-release oxycodone is a long-acting opioid medication and should not be cut in half or crushed to prevent immediate absorption of the entire dose. This medication should be swallowed whole and is administered every 12 hours.
Incorrect Answers:
B. The nurse should tell the client that extended-release oxycodone is a long-acting opioid and is usually prescribed once every 12 hours and not PRN. The client can take oxycodone with food or milk to decrease gastric irritation.
C. The nurse should tell the client that extended-release oxycodone can cause chronic constipation. The nurse should teach the client to increase intake of fluids and fiber to prevent chronic constipation.
D. The nurse should tell the client that when using extended-release oxycodone, a supplemental short-acting opioid medication can be
A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take?
C. Advise the client to tuck his chin downward
A nurse is collecting data from a client who is recovering from a thyroidectomy and has harsh, high-pitched respiratory sounds. Which of the following actions should the nurse take?
Prepare for a tracheostomy
The nurse should notify the provider immediately and prepare for a tracheostomy. Laryngeal stridor is a high-pitched, harsh breathing sound that indicates respiratory distress due to swelling, tetany, or laryngeal spasms.
A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption?
Fortified milk
Fortified milk provides 2.45 mcg of vitamin D, which promotes calcium absorption from the gastrointestinal tract. Adults up to age 70 need 600 international units of vitamin D per day and 800 international units thereafter. Therefore, fortified milk is a good source of vitamin D.
Incorrect Answers:
B. Bananas are a good source of potassium and can reduce bone loss. However, bananas do not promote calcium absorption.
C. Broccoli is a good source of vitamin C, which is important for bone matrix formation. However, steamed broccoli does not promote calcium absorption.
D. Green leafy vegetables are a good source of vitamin K. However, green leafy vegetables contain oxalic acid, which decreases calcium absorption.
A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?
Stabbing chest pain
the nurse should identify that a manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations can include dyspnea, cough, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.
Incorrect Answers:
B. The nurse should identify that this finding is a manifestation of a blood clot in the leg, which can lead to a pulmonary embolism.
C. The nurse should identify that this finding is a manifestation of an infection.
D. The nurse should identify that tachycardia rather than bradycardia is a manifestation of a pulmonary embolism.
A nurse is reviewing laboratory reports for a client who has a Clostridium difficile infection and is receiving vancomycin. Which of the following results should the nurse report to the provider before administering the next dose?
Serum creatinine 2.5 mg/dL
Vancomycin is nephrotoxic and can result in renal failure, which is indicated by elevated levels of creatinine above the expected reference range of 0.5 to 1.3 mg/dL. The nurse should report this laboratory value to the provider prior to administering any further doses of the medication.
Incorrect Answers:
A. Adverse effects of vancomycin do not include anemia, and this value is within the expected reference range.
B. Adverse effects of vancomycin do not include altered glucose levels, and this value is within the expected reference range.
D. Adverse effects of vancomycin do not include altered potassium levels, and this value is within the expected reference range.
A nurse employs a thorough, systematic method for obtaining objective data about a client. Which of the following methods should the nurse use to collect this information?
Physical examination
A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicate that the client has hyperglycemia?
A nurse is caring for a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is disoriented to time and place and has an SaO2 of 87%. The nurse notes generalized petechiae on the client’s skin. Which of the following complications should the nurse suspect?
Fat embolism syndrome
The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels.
Incorrect Answers:
A. The nurse should suspect hypovolemic shock for a client who experiences hypotension following extreme fluid loss, as with uncontrolled bleeding, dehydration, or severe edema.
C. The nurse should suspect thrombophlebitis for a client who reports tenderness and warmth over the involved vein.
D. The nurse should suspect osteomyelitis for a client who has an open wound fracture and reports hyperthermia. Radiographs of the affected bone can show bone loss 7 to 10 days following onset.
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?
Increase the oxygen flow and request an arterial blood gas determination
The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.
Incorrect Answers:
A. Clients who have COPD typically require a nasal cannula with an oxygen flow of 2 to 4 L/min or a Venturi mask delivering up to 40% oxygen.
B. Although the client might require intubation and mechanical ventilation at some point, it is premature to anticipate this before trying other therapeutic interventions to help relieve the client's dyspnea.
D. The nurse should assist the client into a high Fowler's position. Upright positioning allows maximal chest expansion and can help relieve dyspnea. First-line medications for managing dyspnea due to COPD are bronchodilators, cholinergic antagonists, xanthines, and corticosteroids.
A nurse is reinforcing teaching about self-administration of NPH insulin with a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include?
Rotate injection sites within the same area
To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm (1 in) apart, within the same anatomical area.
Incorrect Answers:
A. Because absorption varies with the site of injection, the client should use the same general area such as the thigh or the abdomen each time.
B. The client should roll the vial between the palms, not shake it.
D. NPH insulin is a cloudy suspension. The client should discard other types of insulin the provider prescribes if the solution is cloudy.
A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?
Moro
The newborn extends both arms and legs outward and then draws them back inward in response to a loud noise such as a sudden clap. This is a general indication that the newborn heard the noise.
A nurse is assisting with the plan of care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care?
Check for hypertension
The nurse should check the client for hypertension, which can indicate fluid volume overload.
Incorrect Answers:
A.The nurse should check the client for hyperglycemia because hypercortisolism elevates blood glucose levels.
C. The nurse should weigh the client at the same time each day because treatment decisions are based on these findings.
D. The nurse should have the client save all urine output to record it every 24 hours. An indwelling urinary catheter needlessly exposes the client to a potential urinary tract infection.
A nurse is assisting with the care of a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively?
with the leg on the affected side abducted
The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
Incorrect Answers:
A. Adduction of the client's leg will cause the hip to dislocate, requiring further surgery.
B. External rotation of the client's leg will cause the hip to dislocate, requiring further surgery.
D. Flexion of the client's hip at 90° or greater will cause the hip to dislocate, requiring further surgery.
A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect?
D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
A nurse is reinforcing teaching with a client who has a new prescription for lisinopril. Which of the following should the nurse include in the teaching as an adverse effect of lisinopril?
Tongue swelling
Angioedema is a fatal response that occurs in about 1% of clients who use ACE inhibitors such as lisinopril. Manifestations of angioedema include swelling of the tongue, lips, or pharynx.
Incorrect Answers:
B. ACE inhibitors Lisinopril inhibit the release of aldosterone and can cause potassium retention and hyperkalemia.
C. ACE inhibitors can cause a persistent, dry, and irritating cough. A runny nose (rhinorrhea) is not an adverse effect associated with this type of medication.
D. ACE inhibitors can cause adverse effects such as flushing, pruritus, and rashes. However, bruising is not an adverse effect associated with this medication.
A nurse is collecting data from a client whose potassium level is 2.8 mEq/L. Which of the following findings should the nurse expect?
Decreased bowel sounds
A nurse is reviewing the laboratory reports for a client and notes an elevated thyroid-stimulating hormone (TSH) level. When collecting data from the client, which of the following findings should the nurse expect?
Bradycardia
A nurse is providing teaching for a client following a below-the-knee amputation. Which of the following should the nurse include in the teaching?
Instruct the client to lie prone while in bed
The nurse should instruct the client to lie in a prone position for 20 to 30 minutes every 3 to 4 hours to avoid developing contractures while in bed.
Incorrect Answers:
B. The nurse should instruct the client to sleep on a firm mattress following the procedure. A firm mattress prevents the development of contractures.
C. The nurse should instruct the client to push down the residual limb while in bed. This prepares the limb for the prosthetic and reduces the incidence of phantom pain.
D. The nurse should instruct the client to wrap the residual limb in an elastic bandage to assist with shrinking the limb and preparing it for the prosthesis. The bandage should be wrapped in a figure-8 pattern from a distal to proximal direction. The bandages should be reapplied every 4 to 6 hours or more often, if loose.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
Respiratory alkalosis
Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.
a nurse is reinforcing teaching with a client who has chemotherapy-induced anemia and a prescription for epoetin alfa. The nurse should instruct the client to report which of the following findings as an adverse effect of epoetin alpha?
Hypertension
The nurse should instruct the client to report hypertension, which is an adverse effect of epoetin alfa. Other adverse effects can include headaches, seizures, heart failure, and thromboembolic events related to increased hemoglobin levels.
Incorrect Answers:
B and C. Epoetin alfa is a growth factor that is used to stimulate the production of red blood cells in the bone marrow. It can cause polycythemia vera, not leukocytosis or bone pain.
D. Clients who are receiving chemotherapy have decreased neutrophil counts as a result of the treatment. Therefore, epoetin alfa is used to stimulate the production of red blood cells in the client's bone marrow.