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disease? Incorrect: Antacids should not be taken concurrently with other ulcer drugs such as H2 blockers because they will decrease drug absorption by 10% to 20%.Correct: The GI complications of NSAID use are strongly linked to mucosal injury and the development of gastric ulcers.Incorrect: Although milk-based diets may provide symptom relief, research has shown they do not influence healing and in fact actually act to increase acid secretion. Diet plays no defined role in ulcer development and current management of ulcers.Incorrect: The individual with an ulcer does not need to restrict activity to enhance healing. Most clients are able to continue usual activities, although adequate rest is encouraged. Antacids and H2 receptor antagonists can be taken together. Avoid the use of NSAIDs for pain control. Increase milk products in the diet to enhance healing. Limit physical activity to reduce stomach acid. 2 A nurse admits a 42-year-old female with the following characteristics: excessive sleeping, fatigue, constipation, weight gain, and complaint of intolerance to cold. These signs and symptoms are most consistent with: Incorrect: Although some of the symptoms mentioned would be consistent with acute renal failure (i.e. fatigue, weight gain), there is no mention of the classic symptoms of acute renal failure. These would include signs and symptoms of fluid overload and electrolyte imbalance such as hypertension, neck vein distention, low urine output, confusion.Incorrect: Although fatigue is consistent with aplastic anemia, the remaining symptoms are not. Aplastic anemia results from impaired erythrocyte production and is manifested by pale skin color, fatigue, exertional dyspnea, palpations, low hemoglobin, and signs of bleeding tendency such as petechiae and ecchymosis.Correct: This client presents with some of the classic characteristics of hypothyroidism. Recall that a lack of thyroid hormone results in a general depression of the basal metabolic rate. A typical clinical picture includes fatigue, weakness, intolerance to cold, constipation, menstrual irregularities, reduced appetite, dry skin, edema.Incorrect: The hallmark of diabetes is insulin deficiency manifested by hyperglycemia, polyuria, polydipsia, polyphagia, visual blurring, fatigue, and weight loss. This client does not present with this symptom combination. acute renal failure. aplastic anemia. hypothyroidism. diabetes mellitus. 3 A client newly diagnosed with HIV says to the nurse, "I can't believe this is happening. There must be some new treatments that can help." The most appropriate nursing diagnosis for this client based on his comments would be:
Incorrect: The defining characteristics of altered family processes include verbal hostility between family members and a general lack of communication and respect between family members. Although this may be a problem for the client with HIV, more data is needed to formulate this nursing diagnosis in this situation.Incorrect: The client has not expressed a feeling of aloneness or verbalized discomfort in social situations, which are characteristics of social isolation. Although clients with a diagnosis of HIV or AIDS may experience social isolation, there is insufficient data to validate this as a problem for this individual.Correct: The client's statement is most consistent with anticipatory grieving which is characterized by the normal grief response including anger, denial, disbelief, and guilt.Incorrect: The defining characteristics of ineffective individual coping include verbalization of the inability to cope, inability to problem-solve, altered social participation, inability to meet basic needs and role expectations and inappropriate use of defense mechanisms to mention a few. Although the client is expressing disbelief, there is insufficient data to support a nursing diagnosis of ineffective individual coping. altered family processes. social isolation. anticipatory grieving. ineffective individual coping. 4 The nature of systemic lupus erythematosus (SLE) requires the nurse to teach the patient and family: Incorrect: Pregnancy is not necessarily contraindicated in clients with SLE. Although pregnancy does not induce SLE exacerbations, pregnancy should be planned with the client's primary care provider.Correct: Factors such as fatigue, sun exposure, stress, and infection can exacerbate systemic lupus erythematosus. Nursing interventions should include teaching the client and family measures to reduce stress and cope with the chronic disease.Incorrect: Neither discoid nor systemic lupus erythematosus is a contagious disease. Both are thought to be autoimmune disorders.Incorrect: The lesions of SLE are well demarcated and are relatively benign in nature. The rash is generally confined to the face, scalp, and neck. Although other parts of the body may be involved (i.e. mucous membranes), the rash does not actually spread like an allergic dermatitis (i.e. when an irritant or allergen is spread by the hands to another body part as in poison ivy). birth control measures to prevent pregnancy. strategies to prevent and cope with stress. measures to prevent spread of the disease. methods to diminish spread of skin lesions. 5 A Type I diabetic is prescribed to take Regular and NPH insulin before breakfast. The client administers his insulin at 6:00 a.m. prior to breakfast. The nurse should teach the client to: Incorrect: The onset of NPH insulin is approximately 1-2 hours with peak effect between 6-12 hours. Therefore a snack eaten between breakfast and lunch, when the NPH insulin is beginning to reach it's peak action would be important to prevent hypoglycemia before lunch. In addition, regular or quick acting insulin requires that a supplemental
snack of 15 g of carbohydrate be given to match the peak action of the insulin. Since regular insulin is peaking at 2-4 hours post administration, a 10:00 a.m. snack would be recommended.Incorrect: Because the NPH insulin will still be peaking from approximately 12:00 p.m. to 6:00 p.m., delaying the evening meal (dinner) until after 6:00 p.m. would put the client at risk for hypoglycemia.Incorrect: Carbohydrate intake must be coordinated with the peak action of insulin. Therefore, the client should be taught to consistently eat carbohydrates at meals, ranging from 45-60% of the total caloric intake.Correct: The peak time of NPH insulin is 4-12 hours. If the client takes the NPH insulin at 6:00 a.m., the insulin will be peaking between 12:00 p.m. and 6:00 p.m. Therefore it is important that food be scheduled between this time period to prevent hypoglycemia. avoid any snacks between breakfast and lunch. delay dinner until after 6:00 p.m.. eat a low carbohydrate lunch at noon. schedule a snack at 3:00 p.m.. 6 A client with a fractured femur was recently admitted to the orthopedic unit in traction. In planning care to minimize the risk for fat embolism, the nurse should implement which intervention? Correct: Immobilization, surgery or trauma to the skeletal system, poor hydration and low tidal volume in the lung are predisposing factors to fat embolism syndrome. Nursing interventions to reduce the risk of fat embolism include good respiratory care, adequate hydration, and stable traction. Other measures include: the use of intermittent pneumatic compression, leg elevation, elastic stockings, and medications (anticoagulant, anti-platelet agents).Incorrect: Fat embolism is not related to diet. The use of supplementary oxygen may require an order, particularly to the client with chronic obstructive pulmonary disease. Range of motion is not recommended for the affected leg.Incorrect: A liquid diet is not necessary for the client in traction. Physical therapy is essential in the rehabilitative phase.Incorrect: Sedation and analgesia are not related to the prevention of fat emboli. The client is encouraged to move the unaffected extremities to reduce the risk of fat embolism syndrome, pressure-related skin injury, and muscle soreness. Provide a low-fat, high-carbohydrate diet, give oxygen, and encourage range of motion in the affected leg. Keep the client on a liquid diet, and have physical therapy start the client on an exercise program for upper body strengthening. Maintain sedation and administer intravenous fluids and medications for pain as needed. 7 The nurse is caring for a client who has just developed ventricular tachycardia following a myocardial infarction. The nurse anticipates the client will immediately be given which of the following medications? Incorrect: Atropine sulfate is an anticholinergic drug used to increase the heart rate in symptomatic bradycardia (defined as 40 beats per minute).Incorrect: Epinephrine
is an adrenergic agent that increases the heart rate. This drug would be contraindicated in fast-rate dysrhythmias. It is one of the first line drugs administered during CPR. By constricting peripheral blood vessels, epinephrine shunts blood to the central circulation and increases blood flow to the heart and brain. It is also given for asystole to stimulate electrical and mechanical activity to produce myocardial contraction.Correct: The first line drug for management of serious ventricular dysrhythmias is lidocaine, which decreases myocardial irritability (automaticity) in the ventricles.Incorrect: Nitroglycerin is used to dilate coronary arteries and improve blood flow. It has no antidysrhythmic effect. Atropine sulfate Epinephrine Lidocaine Nitroglycerin 8 During a home visit the nurse determines that the client is experiencing dumping syndrome following his recent total gastrectomy. Which dietary recommendation should the nurse convey to the client? Incorrect: Oral vitamins will have no effect on dumping syndrome. Further, they are of no benefit to the client following total gastrectomy due to loss of intrinsic factor normally secreted by the parietal cells of the stomach. Intrinsic factor is essential for the absorption of vitamin B12. Monthly injection of vitamin B12 will prevent the development of pernicious anemia.Incorrect: Malabsorption of fat may occur after gastrectomy from reduced acid secretion and availability of pancreatic enzymes required for fat absorption. Dumping syndrome occurs because of the rapid entry of hypertonic food into the upper small intestine without undergoing the usual breakdown and dilution in the stomach. This stimulates motility and diarrhea. Preventive measures include a moderate-fat, high-protein diet with limited carbohydrates.Correct: Fluids with meals are discouraged because they increase total volume and further promote diarrhea.Incorrect: Rest on the left side for 20-30 minutes after eating is thought to delay gastric emptying and may be helpful for some individuals. Begin taking a vitamin B complex supplement. Eat a high carbohydrate, low fat, low protein diet. Decrease fluid intake with meals. Go for a slow, short walk after eating. 9 A client with asthma goes into status asthmaticus. Which clinical signs, if present, would indicate that intubation and mechanical ventilation are needed? Incorrect: Both hyperresonance (air-trapping) and tachypnea are characteristic of an acute asthma attack.Incorrect: Severe inspiratory and expiratory wheezing is consistent with an acute asthma attack. Clients with status asthmaticus may be moving minimal amounts of air into and out of the lungs therefore audible wheezing may NOT be present.Correct: These blood gas values indicate respiratory acidosis and hypoxemia. This occurs as a result of a prolonged attack where respiratory muscle exhaustion causes hypoventilation. If respiratory acidosis and hypoxemia are present, intubation and
the immediate priority is maintaining a patent airway and adequate oxygenation to support cerebral perfusion. Decrease the complications of disuse.Incorrect: Tachycardia and an elevated blood pressure are expected findings during an acute asthma attack. Hyperresonance and tachypnea Severe inspiratory and expiratory wheezing pH 7. during the acute phase of a stroke. and cerebral perfusion.Incorrect: Problems with urinary incontinence are common after stroke and the plan of care during hospitalization and rehabilitation will include measures to restore continence. self-care deficit. Because of motor of sensory deficits. and/or injuries.ventilatory assistance may be required if oxygen and other treatment measures are ineffective. and secretions. BP 150/88 10 Which nursing intervention is the priority for care of the client during the acute phase of a cerebrovascular accident (CVA)? Incorrect: Following a CVA clients are at risk for a variety of complications associated with immobility and subsequent disuse such as contractures and skin breakdown. Although a nursing care plan would be incomplete without addressing the coping needs of the client and family. Assess for bladder distention. This is a result of changes in intrapleural pressure during respiration that occurs in obstructive airway disease. clients with status asthmaticus may exhibit pulsus paradoxus. While preventive nursing care measures are incorporated into the daily routine. the client with a CVA is at risk of aspiration of food. However. the immediate priority post CVA is respiratory and neurological assessment and promotion of oxygenation to the brain. which one would most effectively address primary prevention as it relates to drug management in the elderly population? Incorrect: The nursing diagnosis that most effectively guides primary prevention of drug reactions and interactions involves identifying the risk and taking measures to prevent adverse reactions. Maintain effective coping by the family. Although elderly clients taking multiple drugs are at greater risk for adverse reactions because of complex drug regimens and age-related physiological changes. PO2 74 mm Hg Pulse 110/minute.Incorrect: The effects of a CVA are life altering. 11 Of the following nursing diagnoses. fluid. However. challenge the coping abilities of the client and family. Pulsus paradoxus is an accentuation of the normal decrease in systolic arterial pressure with inspiration. a diagnosis of 'self-care deficit related to .Correct: During the acute phase of a cerebrovascular accident it is essential to assess respiratory function and maintain a patent airway to support oxygenation and cerebral perfusion. the immediate care priority in the acute phase of stroke is airway. Monitor the status of respiratory function. PCO2 55 mm Hg. oxygenation.32. The emotional changes and physical limitations that commonly occur.
These drugs cause smooth muscle relaxation and bronchodilation and start to act within 10 .Correct: The 1st drug of choice in an acute asthma attack is a short-acting inhaled beta2-adrengergic agonist such as albuterol sulfate (Proventil) or metaproterenol sulfate (Alupent). ambulation supports oxygenation through natural deep breathing and assists in the elimination of residual anesthetic. Narcotic analgesics are the most effective in relieving pain during the immediate postoperative period and should be encouraged to prevent severe pain and enhance activity. adverse reactions and side effects is best addressed using a potential nursing diagnosis that identifies risk factors in the elderly population. It is used in maintenance therapy in chronic.Correct: Venous pooling and pelvic congestion are common complications after hysterectomy. Efforts should be taken to avoid positioning the client with the knees bent since this promotes pelvic congestion. The other answer options are nursing diagnosis that address 'actual' problems. this diagnosis does not focus on problem prevention. Early ambulation Compression stockings Narcotic analgesics Pillows under the knees 13 The nurse is teaching an asthmatic client how to treat episodes of acute bronchoconstriction.Incorrect: Although elderly clients may be noncompliant with the drug regimen due to lack of sufficient knowledge regarding drug administration.Incorrect: The risk of thromboembolism is significant in the post-hysterectomy client because of venous pooling and pelvic congestion. coughing and deep breathing. Nursing interventions to prevent thromboembolism include compression stockings and leg/foot flexion and extension exercises. the nurse should teach the client to immediately take the: Incorrect: The anticholinergic Atrovent is ineffective in acute bronchospasm when a rapid response is required. Which of the following interventions would be contraindicated? Incorrect: Frequent ambulation is encouraged as the most reliable means of stimulating peristalsis. and early ambulation.Correct: Because elders consume disproportionately more of all kinds of drugs than do middle-aged adults. 'risk for injury related to polypharmacy' is the nursing diagnosis that would focus on prevention of complications for this group of individuals.Incorrect: Pain relief should be promoted not only for comfort but to promote frequent turning. if prescribed.Incorrect: The prevention of drug mismanagement. Of the following inhaled agents. Self-care deficits related to adverse reactions to prescribed drugs Body image disturbance related to drug side effects Noncompliance related to knowledge deficit Risk for injury related to polypharmacy 12 The nurse is planning care for a 48-year-old female following a total hysterectomy. especially if the lithotomy position was used. In addition. bronchoconstrictive conditions such as chronic bronchitis and emphysema.adverse reactions to prescribed drugs' addresses an actual problem with drug management.
15 A preoperative order is written for meperidine 50 mg IM. it should be noted that the inhaled beta2-agonist should be given first to open the airway. corticosteroid (Azmacort). as well as the degree of pain. Meperidine binds to opiate receptors in the central nervous system resulting in altered perception of and response to painful stimuli. palpating arterial pulses gives the most information about the patency of the graft and perfusion of blood to areas below the bypass. circulation. which increases the effectiveness of beta2-adrengergic bronchodilators.Incorrect: Monitoring ECG activity is a critical nursing intervention because clients with vascular disease commonly have problems with CAD or hypertension. However. Mast cell stabilizers prevent the release of bronchoconstrictive and inflammatory substances when mast cells are confronted with allergens.Incorrect: Inhaled steroids do not play a role in acute situations. It . beta2-adrenergic agonist (Albuterol).Incorrect: Because coronary artery disease and hypertension are common in clients with vascular disease. Check the electrocardiogram every four hours. Record the client's intake and output. sensation. which will be more effective when inhaled deeper into the lung. The drugs in this category are used only for prophylaxis and are not effective in acute bronchospasm. pallor. Check the equality of the client's hand grasps. Palpate all arterial pulse sites as frequently as every hour. Another important action is to increase the number and sensitivity of beta2-adrenergic receptors. and movement.Incorrect: Cromolyn (Intal) is used to prevent acute asthma attacks in clients with chronic asthma.minutes. Corticosteroids primarily work by suppressing inflammation in the airways. 14 A client is admitted to the Intensive Care Unit following a femoral-popliteal bypass graft. followed by the inhaled steroid. Which intervention provides the most relevant data about graft patency? Incorrect: This activity evaluates neurological status and would not provide any significant data regarding graft patency. anticholinergic (Atrovent). the client's blood pressure can be expected to decrease as pain diminishes. Therefore. palpating arterial pulses gives the most information about the patency of the graft and perfusion of blood to areas below the bypass. As a secondary response. dysrhythmias or cardiac failure are potential complications of vascular surgery. restenosis. In maintenance therapy. mast cell stabilizer (Cromolyn). However. The nurse should monitor the client's peripheral pulses and limb temperature. Which desired effects can the nurse anticipate following drug administration? Incorrect: Anticholinergic agents such as Robinul are often given preoperatively to inhibit salivation and excessive respiratory secretions.Correct: Meperidine (Demerol) is an opioid analgesic.Correct: Graft patency is a priority concern in the postoperative client because the risk of reocclusion from thrombosis. or debris is significant. and perfusion. thereby decreasing mucus secretion and edema. accurate documentation of I & O is also essential to quality nursing care to detect alterations in cardiac output and renal perfusion.
Studies have shown that clients receive the most benefit from O2 therapy if the oxygen is used continuously. commonly associated with dysrhythmias such as atrial fibrillation. The Venturi mask can also be used to deliver O2 at controlled levels. Which signs/symptoms. the standard of care is to: Correct: Breathing very high concentrations of O2 for prolonged periods is associated with acute respiratory distress syndrome. PCO2 50 mm Hg or more.Incorrect: It is true that precautions must be taken when giving O2 to clients with COPD. Physiological criteria for acute respiratory failure include sudden onset of PO2 50 mmHg or less. administer the least amount of O2 that achieves an acceptable PO2. Decreased salivation and mucous production Pain reduction and decreased blood pressure Reduced nausea and increased peristalsis Sedation and amnesia following the surgical procedure 21 When treating clients with chronic obstructive pulmonary disease (COPD) who are hypoxemic. alone it is not a criterion for diagnosing acute respiratory failure. a sedative/ hypnotic that induces short-term sedation and postoperative amnesia. use a nasal cannula rather than a facial mask.Incorrect: The therapeutic effects described are characteristic of Versed. if present. institute O2 therapy only when dyspnea occurs. A drug expected to have these effects would be metoclopramide (Reglan).Incorrect: Clients with COPD who are carbon dioxide retainers must receive supplemental O2 by controlled O2 delivery devices. maintain low-flow O2 under all circumstances. low O2 levels produce the drive to breathe.Incorrect: Jugular vein distention is a clinical manifestation of the client's congestive heart failure.35 or less. An irregular apical pulse is not a component of the physiological criteria used to diagnose acute respiratory failure.Correct: Acute respiratory failure is defined as any rapid change in respiration resulting in hypoxemia. When low-flow O2 is desired. and pH 7. Recall that opioids can have a constipating effect. oxygen is given by nasal cannula.Incorrect: An irregular apical pulse in this situation may be associated with the client's congestive heart failure. 22 A client is being treated for pulmonary edema secondary to congestive heart failure.Incorrect: This is a common misunderstanding by clients requiring O2 therapy. would suggest to the nurse the onset of acute respiratory failure? Incorrect: Although acute dyspnea will occur as a result of hypoxemia. hypercarbia. A firm general principle is to use the lowest amount of O2 that will achieve an acceptable PO2. Acute dyspnea Irregular apical pulse .should be noted that hypotension can be an adverse reaction.Incorrect: Meperidine is not known to have any antiemetic or GI stimulant effects. These persons chronically retain carbon dioxide. or both.
creating an imbalance between excitatory and inhibitory neuronal activity. increasing the action of acetylcholine. are often prescribed to decrease the excitatory effects of ACh. resulting in loss of the ability to refine voluntary movement. PCO2 > 50 mm Hg 23 The primary care provider prescribes levodopa for a 68-year-old male diagnosed with Parkinson's disease. it can indicate which type of infarction has occurred. the nurse knows that this diagnostic tool is important because the ECG: Incorrect: Although ECG characteristics may lend support to the diagnosis of angina and/or infarction. Insufficient dopamine allows large numbers of excitatory acetylcholine (ACh) secreting neurons to remain active. Injured myocardial cells release several enzymes that are important indicators of acute myocardial infarction.). replaces the need for stress testing. The nurse knows that this drug helps reduce rigidity by: Incorrect: A deficient amount of norepinephrine is thought to be a contributing factor in depression. such as Cogentin. is a more reliable diagnostic tool than blood studies. duration etc. Parkinson's disease does not involve this neurotransmitter. Therefore. Anticholinergic agents.Incorrect: Parkinson's disease involves deficient amounts of dopamine. it does not give definitive data that would help distinguish between stable and unstable angina.Incorrect: Stress testing is an important diagnostic tool different from the 12lead ECG. The client's history often distinguishes between types of angina (i. the ECG is an important diagnostic tool.Jugular vein distention PO2 < 50 mm Hg. . inhibiting the reuptake of serotonin. Parkinson's disease does not involve this neurotransmitter.Incorrect: A deficiency of norepinephrine and/or serotonin is thought to be a component of depression. Selective serotonin reuptake inhibitors (SSRI) are antidepressants that increase the amounts of these neurotransmitters in the CNS. leading to a decrease in the amount of dopamine. enhancing the release of norepinephrine. what relieves the pain. Because ECG findings correlate to anatomical locations. Some of the antidepressants such as the monoamine oxidase inhibitors (MAO) act by facilitating release of norepinephrine in nerve terminals. This results in the characteristic excessive excitation of neurons that occurs in Parkinson's disease interfering with control or initiation of voluntary.Incorrect: Blood studies are equally important but can take longer to analyze. 24 When evaluating serial electrocardiograms (ECGs) for a client with coronary artery disease.e. can help distinguish between stable and unstable angina.Correct: Parkinson's disease results from degeneration of the substantia nigra. restoring deficient dopamine.Correct: ST segment elevation is the hallmark of acute myocardial ischemia leading to infarction. Levodopa is converted to dopamine in the central nervous system. provocative factors. An exercise stress test demonstrates the significance of coronary artery blockages and can indicate areas of the myocardium that do not receive adequate perfusion at peak exercise.
and she is irritable. Recall that CO2 when combined with H2O forms H2CO3 or carbonic acid. Respiratory acidosis would be reflected in an elevated PCO2 when carbon dioxide is retained and more carbonic acid is formed. intercostal retractions Late: Adventitious breath sounds. Therefore. 25 Acute respiratory distress syndrome (ARDS) can be detected early in high-risk clients. signs of hypoxia occur including cyanosis and tachycardia. Incorrect: Early in the course of ARDS chest auscultation is clear. PCO2 12 mmHg. we can eliminate alkalosis as a correct choice. Late: Tachycardia. early indicators include dyspnea. hyperventilation. cough. The client's low PCO2 does not match with acidosis. cyanosis. The insulin deficiency prevents normal utilization of serum glucose by the cells. The pH is acidotic (< 7. the PCO2 does not indicate respiratory acidosis. This occurs as a result of increased pulmonary capillary pressures and RBCs entering the alveoli. and labored breathing. Therefore. if the PCO2 is low. Ketones cause the blood pH to drop. restlessness. infection. Grunting respirations and shallow breathing are also late signs as respiratory fatigue and hypoxia occur. The body is forced to break down fat and protein stores for energy resulting in ketone bodies accumulating in the blood. Diabetic ketoacidosis occurs most often in clients with type I IDDM who experience illness. shallow breathing Pulm edema: A productive cough with bloody or frothy sputum Dyspnea.wave abnormalities can signal injury and/or infarction. mucous membranes are dry. respirations are rapid and deep.Incorrect: Although the low PCO2 is consistent with respiratory alkalosis. Which of the following are early manifestations of ARDS? Incorrect: These are late signs of ARDS. The client becomes fatigued as the work of breathing increases as evidenced by intercostal retractions. the pH indicates acidosis. and hyperventilation 26 A client is admitted to the emergency department with diabetes mellitus and a blood sugar of 620 mg/dl. restlessness. As the leakage of fluid into the interstitial and intra-alveolar spaces increases. indicating CO2 is being . Her skin is flushed and warm. then less carbonic acid is formed. HCO3 12 mEq/L. or trauma. grunting respirations. Correct: Although clinical presentation will vary depending on the pathophysiology contributing to ARDS.18. blood-tinged or frothy sputum occur with pulmonary edema. In other words. As alveoli collapse and gas exchange is impaired.Correct: The imbalance is metabolic acidosis suggested immediately by the client's history and clinical manifestations. The ABG results confirm the client is in: Incorrect: Although the pH does indicate acidosis.35). terminal airways become filled with fluid and adventitious breath sounds are auscultated. the low PCO2 is not the cause of the acidosis but is decreased. Arterial blood gas (ABG) values reveal pH 7. Incorrect: Generally.
Obesity is an important risk factor in the incidence of hypertension. This is a compensatory response to the metabolic acidosis indicated by the low HCO3. persons of Hispanic culture have been noted to be at higher risk. hyperventilation. 9 inches. The metabolic acidosis is only partially compensated as indicated by the abnormal pH. 5 feet. uncompensated.Correct: Age is the primary risk factor for hypertension. her culture does not place her at high risk. This client has two risk factors. this client is at low risk since her weight is within ideal range for her height.Incorrect: Although this female is the oldest of the four choices. the CVP is valuable in assessing fluid volume excess or deficit. She does not have any risk factors listed. respiratory alkalosis. It is more common among men than women until after menopause. This client has two risk factors.blown-off as a result of the client's rapid and deep respirations. Because 60% of the blood volume is in the venous system. Although elevated cholesterol and triglyceride levels are correlated with coronary artery disease and hypertension. we can immediately eliminate alkalosis as a correct interpretation. This client has five risk factors. referred to as Kussmaul's respirations. The nurse determines the most recent CVP measurement to be very low. weight 145 lbs.Incorrect: The pH is consistent with acidosis since it is less than 7.Correct: CVP is the measurement of systemic venous pressure at the level of the right atrium. this client's cholesterol level is at the upper edge of normal. it does provide information about fluid volume and therefore could indirectly suggest blood pressure changes. metabolic acidosis. decreased CVP is caused by hypovolemia. and is twice as prevalent and more severe among African Americans.Incorrect: Aside from direct observation. Smoking and excess alcohol use are also risk factors. In the case of a low CVP reading. hypertension.35. . Heredity also plays a role in hypertensive disease. The CVP does not provide information about ventilation. Therefore. the best tool for analyzing ventilation status is arterial blood gas analysis. metabolic alkalosis. partially compensated.Incorrect: The CVP does not give any information about oxygenation. The HCO3 is low in proportion to the increase in fixed acids in the blood (in this case ketones). fully compensated. However. respiratory acidosis. partially compensated. Usually.Incorrect: This client's age represents a risk factor. hypovolemia. hypoxia. 27 The nurse is evaluating central venous pressure (CVP) measurements for a client with multi-system injuries who was recently admitted to the intensive care unit. However. Arterial blood gas analysis can be obtained via an arterial catheter for assessment of oxygenation status. 28 Which of the following individuals has the most risk factors for developing hypertensive disease? A/an: Incorrect: Based on the data. 42-year-old white female. This reading indicates: Incorrect: The CVP does not give any direct information about pressure in the arterial system. hypovolemia is the likely cause and blood pressure would be decreased.
music therapy. progressive relaxation. distraction. The techniques of guided imagery. Ask the primary care provider to order a patient-controlled analgesic pump. music therapy. guided imagery and hypnosis. A cascade of physiologic responses occurs that contribute to the increased difficulty in controlling the perception of pain. distraction. are also effective in the reduction of perceived pain. intraocular pressure rises as a result of structural resistance (open-angle) or complete obstruction (closed-angle) to the outflow of aqueous humor through the chamber located between the iris and cornea. such as relaxation technique. 30 As part of the collaborative plan of care. and hypnosis that are used as an adjunct to analgesia may be more effective than medication alone. either analgesic or nonpharmacologic therapies. Non-pharmacologic treatments. which class of medications would the nurse expect the practitioner to prescribe for the client with newly diagnosed glaucoma? Correct: Recall that in glaucoma. Pressure is placed on the optic nerve and blindness can result. 80-year-old Asian female whose mother had coronary artery disease. Sedation promotes drowsiness and does not relieve pain. Request that the primary care provider prescribe sedative medication. Correct: Pain relief with analgesic agents.64-year-old Hispanic male. distraction. Intramuscular administration is contraindicated due to the erratic and diminished circulation to muscle tissue. are also effective in the reduction of perceived pain. are most effective if used at or just below the pain threshold. Incorrect: The nurse may teach the client with chronic pain the use of various nonpharmacologic therapies for pain management. A more effective strategy for pain management is to intervene before it escalates. Encourage the use of analgesia and non-pharmacologic methods of pain control. such as narcotics or non-steroidal antiinflammatory agents. The nurse planning this client's care should consider which intervention for pain control? Incorrect: The client with burn injury experiences pain that requires analgesia. music therapy. Miotics (direct-acting cholinergics) such as pilocarpine hydrochloride are commonly used to treat glaucoma. 40 pack year history of smoking. These drugs constrict the pupil so that the ciliary muscle is contracted which allows better circulation of aqueous humor. usually narcotics in the acute phase. 29 A client in the rehabilitative phase of a burn injury is having difficulty with pain management. Teach the client to minimize the use of analgesia to prevent a tolerance effect. 76-year-old black male. Non-pharmacologic treatments. such as relaxation technique. may be obtained through the oral or intravenous routes. guided imagery and hypnosis.Incorrect: Methods to control pain. alcoholic. cholesterol 180 mg/dl.Incorrect: Antibacterial agents such as tobramycin or gentamicin sulfate are prescribed as anti-infective agents and are not routinely given to clients with .
and leukemia because of the impaired immunologic response.Correct: Shingles.Incorrect: Herpes zoster is a viral infection. Although assessing voiding patterns is important in the client with prostatic disease. occurs after exposure to the varicella-zoster virus (chickenpox). caused by the herpes zoster virus. also known as shingles. corticosteroids decrease the effects of all drugs used for glaucoma.glaucoma unless surgical intervention is required. The use of over-the-counter medications that impair clotting. is an infection of the dorsal nerve root ganglion. Shingles frequently occurs in the host with immunosuppression. Therefore. is a viral infection not related to a vaccination for measles. Which is the most likely rationale for this client to develop herpes zoster infection? Incorrect: Shingles. known as shingles. However.Incorrect: Again. "Do you take aspirin or any blood thinners?" "How often do you get up during the night to urinate?" "How much did you urinate last time you voided?" "When did you last take your medications?" 32 A client with Acquired Immunodeficiency Syndrome (AIDS) develops shingles on the trunk. an ocular steroid may be prescribed following laser surgery.Incorrect: Systemic corticosteroids can raise intraocular pressure and even cause glaucoma. determining degree of nocturia is not the most essential piece of preoperative information. . caused by the herpes zoster virus. mumps or rubella. The client never had chicken pox as a child. Direct-acting miotic agent Ophthalmic antibacterial agent Systemic Anticholinergic Corticosteroid 31 The nurse is obtaining a health history from the client scheduled for a transurethral resection of the prostate (TURP) in the morning. lymphoma. Ophthalmic atropine solution is classified as a cycloplegic mydriatic causing pupillary dilation.Incorrect: This would be an essential question to ask the client immediately prior to surgery. such as ASA and NSAIDs should be documented. Increased incidence of herpes zoster occurs in clients with AIDS.Incorrect: Systemic anticholinergics such as atropine would be contraindicated. especially in the client with closed or narrowangle glaucoma. this would be an important question to ask the client the morning of surgery. Questions regarding over-the-counter drugs and prescribed anticoagulants are essential to the client's safety.Incorrect: Although important to the overall assessment of the client with prostatic dysfunction.Incorrect: Herpes zoster. because of the anticholinergic effects (mydriasis or pupillary dilation). Which question should the nurse ask that is essential to the safety of the client prior to surgery? Correct: Since bleeding can be a common postoperative problem the nurse must carefully assess the client's medication history. the question regarding aspirin therapy is essential to the client's safety. These drugs are hazardous in glaucoma.
bubbling is expected because air in the chest is being expelled. . without proper dilution severe cardiac dysrhythmias could result. The water level will rise on inspiration and fall on expiration. give the potassium as a bolus preparation. 2. In clients unable to tolerate large fluid volumes. NOTE: if the client is not on a fluid restriction. excessive bubbling may indicate a leak in the system.Incorrect: Intravenous potassium should be diluted in large quantities of solution.5 mEq/L) and no ECG manifestations. more concentrated K+ solutions are used such as 10-20 mEq/100 mL. potassium should NEVER be given as a bolus. 33 A client has a chest tube following a chest injury. dilute the potassium preparation in at least 20 mL sodium chloride.Correct: To minimize irritation of the peripheral vein. tidaling or fluctuation in the water-seal chamber will occur.250 ml) could be initiated as the primary line to facilitate the potassium infusion and then discontinued after drug therapy. Continuous bubbling in the water-seal chamber of the closed drainage system would alert the nurse to which of the following? Incorrect: Absence of tidaling of fluid in the water-seal chamber could suggest that the tubing is obstructed by a kink or dependent fluid has filled a loop of tubing.Correct: Unexpected or continuous bubbling in the water-seal chamber indicates an air leak in the closed system. and if infiltration occurred during administration. 100 . the best way to safely administer potassium IV is to dilute the potassium in large volumes (i. The affected lung is now fully expanded. Herpes zoster is an allergic reaction to medication.e. continuous bubbling suggests a leak in the system. and 30 mEq/L for clients with less severe hypokalemia (i.Incorrect: Continuous bubbling in the water-seal chamber is not an indication that the drainage system is properly functioning. The recommended dilution is a solution that contains no more than 60 mEq/L in clients with a K+ < 2.0 mEq/L and ECG abnormalities. and the situation is not emergent. The potassium would be insufficiently diluted. To avoid fluid overload. In addition. Efforts must be made to identify the source of the leak.e. mumps.Incorrect: Tidaling of fluid in the tubing and/or water-seal chamber will occur as long as a pneumothorax is present to any degree. The pneumothorax is expanding. severe tissue injury could occur. An air leak may be present in the closed system. The water-seal drainage is properly functioning. 34 To prevent vessel and/or tissue injury during intravenous infusion of a concentrated potassium solution to the client with severe hypokalemia the nurse should: Incorrect: Intravenous potassium is extremely irritating to blood vessels and subcutaneous tissue. As described above. 40 mEq/liter). a concentrated KCl solution should be piggybacked into a running primary line to help dilute the solution. During forceful expiration or coughing. and rubella vaccination. administer the infusion IV push slowly over 5 minutes. It also may suggest lung re-expansion. In the presence of a pneumothorax. As described below.Incorrect: For the same reasons as discussed above. a small volume of sodium chloride (i.Client received a recent measles. Potassium should NEVER be given IV push.e.
reduced urine output and increased specific gravity.e. or remain engorged when elevated above the heart is also indication of fluid volume excess. increase oxygenation of myocardial tissue. Morphine is not a coronary artery vasodilator.Correct: Morphine sulfate has a vasodilating effect on peripheral vessels thereby causing venous pooling and decreasing venous return (preload). and behavioral changes such as restlessness and agitation. 35 An adult client has been vomiting persistently for 3 days. On admission he weighed 155 pounds. sticky mucous membranes. As the serum sodium rises due to loss of water. and peripheral edema suggest fluid volume excess with accumulation of fluid in the lungs. the most effective immediate intervention to increase myocardial oxygen supply is via supplemental oxygen. In addition.piggyback the solution into a primary line.Correct: The client is exhibiting clinical manifestations of dehydration due to severe diarrhea occurring with inadequate volume replacement or fluid replacement with hyperosmolar solution. This helps to reduce the workload of the heart. Dehydration would cause the blood and urine to be concentration with a resultant increase in urine specific gravity and serum osmolality. dyspnea. increased myocardial oxygen demand). rough dry tongue. and peripheral edema 36 The client experiencing an acute myocardial infarction can be given Morphine sulfate IV every 2-3 hours prn chest pain. The primary function of Morphine sulfate in this situation is to: Incorrect: Increases in oxygenation of myocardial tissue occur through the use of vasodilators such as the nitrates. dry mucous membranes. increased serum osmolality. tachycardia. He states he weighed 167 pounds one week ago. . weight loss. Both a fluid volume deficit and hypernatremia are present. The primary function of morphine is to decrease pain and the associated deleterious effects of pain (i.Incorrect: Antiplatelet agents such as aspirin work by inhibiting platelet aggregation resulting in reduced clot formation. Bounding pulse and hand veins are slow to empty Decreased urine specific gravity and serum osmolality Postural hypotension and thirst Cough. dyspnea. The analgesic effect of morphine also helps reduce the client's anxiety as chest pain is reduced or eliminated. Fluid volume deficit is manifested by postural hypotension (a key sign). Serum sodium is 155 mEq/L. symptoms include extreme thirst and dry.Incorrect: A reduction in urine specific gravity and serum osmolality indicate dilution of the vascular space as would occur in fluid volume excess. Hand veins that are slow to empty.Incorrect: A combination of cough. Morphine does not have any affect on platelet aggregation.Incorrect: Coronary artery vasodilators work by increasing blood flow to the myocardium. Which signs/symptoms would the nurse expect to find on assessment? Incorrect: A bounding pulse is characteristic of hypervolemia when excess fluid is in the vascular space. elevated body temperature.
decrease anxiety and reduce cardiac workload. and apraxia is the inability to properly use objects or carry out a learned sequence of movements. During treatment with an intracavity implant. Place objects within the client's visual field. inhibit platelet aggregation. "I can expect a foul-smelling vaginal discharge.Correct: This statement indicates the need for more teaching since the client with a cervical implant should select a low-residue diet to prevent abdominal distention. Which one addresses the problem of unilateral neglect? Incorrect: This nursing intervention is aimed at addressing the problem of fluent aphasia where the individual has difficulty comprehending speech but may be able to speak fluently. Teaching the client to monitor the position of the right side will help the person be aware of that side and promote safety. The bowel is cleansed before therapy and a lowresidue diet is maintained during treatment to prevent bowel distention." "I will select high fiber foods throughout the treatment. If the kidneys were .Incorrect: This nursing intervention is aimed at addressing the problem of hemianopsia (loss of vision in a portion of the visual field). Face the client and speak slowly and distinctly. Teach the client to monitor position of the right side. More teaching is required if the client states: Incorrect: A foul-smelling vaginal discharge is expected from destruction and sloughing of cells. including the limitation of time at the bedside. What conclusion can the nurse make? Incorrect: These ABG values are within normal range." 38 In planning nursing care for the client with a left hemisphere stroke." "I will remain in bed while the implant is in place. the nurse develops the following interventions. 39 While caring for a postoperative client the nurse checks the most recent arterial blood gas (ABG) values which reveal a pH 7.37.Incorrect: This intervention is aimed at addressing the problems of agnosia/apraxia.Incorrect: The client must be kept in bed and as flat as possible to prevent dislodgement of the radioactive substance.Correct: Unilateral neglect involves a distortion in body image in which the individual ignores the affected side of the body. Agnosia is the inability to recognize familiar objects. Verbally cue the client about correct use of objects. Turning from side to side is permitted for comfort. Visitors will be held to the same precautions as staff.Incorrect: Radiation precautions for internal radiotherapy include the principles of time and distance. 37 A post-menopausal female diagnosed with cervical cancer is admitted for placement of a radioactive implant." "I realize time for visitors will be restricted. it is important that all untreated tissues remain in their normal position and not come in contact with the radioactive device. PCO2 of 40 mmHg and HCO3 of 24 mEq/L. increase blood flow to the myocardium.
(c) estimate fluid lost as perspiration. Fatigue may last from 3-12 months. PCO2 and HCO3 levels are all within normal range. glomerular filtration rate decreases. 'uncaught' emesis or wound exudate. at the same time. Kidneys are retaining fixed acids. 41 Which clinical manifestation is the most reliable indicator for a fluid imbalance? Incorrect: Blood pressure changes often do occur with fluid and electrolyte disturbances.Correct: Daily weight. Carbonic acid/bicarbonate ratio is normal. the client's energy level returns.Incorrect: Since the pH. Blood pressure Daily weight . (b) consider that parenteral fluid bottles are overfilled.Correct: Normally. This is manifested by increased serum urea nitrogen (BUN) and creatinine levels.Incorrect: During the recovery phase of ARF the client's energy levels generally improve but may continue to decrease. there is neither acidosis nor alkalosis. Respiratory alkalosis is present. in similar clothing is the most reliable means of estimating fluid gains/losses. (d) record intake or output. skin color changes do not typically occur in fluid or electrolyte imbalances.retaining fixed acids there would be evidence of metabolic acidosis with a lowered pH and HCO3. urine output increases by 3 to 5 liters per day. In addition. BUN and creatinine levels stabilize. 40 In planning the care of an adult client with acute renal failure (ARF) caused by a drug overdose. however many other factors raise or lower blood pressure (i. the BUN and creatinine levels stabilize. Intake AND output should be assessed to determine fluid gains/losses.Incorrect: A reduction of the glomerular filtration rate occurs in the oliguric phase when the kidney is unable to excrete metabolic wastes. The client is hyperventilating.e. However. Since the client's PCO2 and HCO3 levels are within normal range one can infer that the carbonic acid/bicarbonate ratio is normal. I & O is not considered the most reliable indicator of fluid gains or losses because accuracy is hampered by many factors such as failure to (a) explain I & O to the client and family. the body maintains a ratio of carbonic acid (CO2 plus H2O) and bicarbonate at 1:20. This ratio keeps the pH within normal limits.Incorrect: Skin turgor is not considered a reliable indicator of hydration especially in the elderly because of changes in skin elasticity.Incorrect: If the client were hyperventilating the PCO2 would most likely be low since carbon dioxide would be blown off. coronary artery disease. the pH would be elevated and the PCO2 would be below normal. If respiratory alkalosis were present.Incorrect: A marked increase in urine output occurs in the diuretic phase of acute renal failure due to a decline in the concentrating ability of the renal tubules and the osmotic diuretic effect of a high BUN. the nurse is aware that the recovery phase of the nephrons occurs when: Correct: During the recovery phase of acute renal failure. stress).Incorrect: Urine output only measures the integrity of the urinary system.
This client would be categorized as having/being: Correct: In the past.Incorrect: Although the arterial pH indicates mild acidemia. AIDS-related complex. The priority focus should be on rehydration.Incorrect: Although it is important to determine if the client with DKA is septic.Incorrect: In this staging system. persistent fevers. it is not the highest priority. Serum potassium 3. However. He has been admitted to the medical unit with a diagnosis of Pneumocystis carinii pneumonia. immunosuppression is different from immunodeficiency. this client's arterial pH does not indicate severe acidosis. HIV positive. IV potassium will be replaced once rehydration is achieved and renal output is established. involuntary weight loss or diarrhea.Hourly urinary output Skin turgor and color 42 A client is admitted to the emergency department with a diagnosis of diabetic ketoacidosis. immunosuppression. the client's WBC is only slightly elevated and may represent leukocytosis commonly seen in DKA.34 WBC 11. On the other hand.2 mEq/L Dehydration Arterial pH 7. Which presenting sign/symptom would the nurse expect the physician to give highest priority? Incorrect: Although the serum potassium level is low. Recall that hyperglycemia causes an osmotic diuresis resulting in dehydration.Correct: A priority intervention in treating the client with diabetic ketoacidosis (DKA) is rehydration.Incorrect: In this informal staging system. This can lead to metabolic acidosis because ketones are acidic and they are retained in the presence of dehydration and decreased urine output. The pH is low because in the presence of insulin deficiency the liver will produce excessive ketones that are acidic. immunosuppression involves an inhibition of the formation of antibodies to antigens that may be present.0 and client is exhibiting shock or dysrhythmia. treatment with sodium bicarbonate is not indicated unless pH is < 7.000/mm3 43 A young male client had a positive ELISA and Western blot test for HIV three years ago. Priorities in management of DKA center on rehydration and IV insulin to control gluconeogensis and ketogenesis. AIDS is a syndrome involving immunodeficiency from depletion of T4 helper cells resulting in a dramatic loss of the protective immune response. Pneumocystis carinii pneumonia is the most common opportunistic infection associated with HIV infection. . clinicians used an informal staging system categorizing clients who have experienced an opportunistic infection as having AIDS. AIDS.Incorrect: Although the end result may be similar. those clients classified as having AIDS-related complex exhibited constitutional symptoms including persistent generalized lymphadenopathy. HIV positive referred to those clients who were completely asymptomatic but HIV positive.
Incorrect: Family visitation is important to every client.Incorrect: Although rest and careful management of energy levels is important.Incorrect: Clients with cortisol excess are usually overweight as a result of changes in fat metabolism. however.Incorrect: Although it is not necessary to coordinate breathing as carefully as it is with the standard inhaler. delivers medication at a prescribed dosage. family visitation should not be restricted to once per shift for the purposes of preventing pneumonia. The nurse should assist the client in restricting calories.44 Which is an appropriate nursing care goal for the client with Cushing syndrome? Incorrect: Fluid volume excess is the primary concern in clients with Cushing's syndrome. helps clients form a tight seal with the mouth. ensures each dose is used more efficiently. each dose is used more efficiently. The most accurate response by the nurse is that the spacer: Incorrect: The correct use of an inhaler with a spacer entails positioning the nebulizer in the mouth WITHOUT sealing the lips around it. especially those individuals in the intensive care unit.Incorrect: The metered dose inhaler delivers a prescribed dose into the spacer. These changes make persons vulnerable to viral and fungal infections. eliminates the need to coordinate breathing with the inhaler.Correct: Because large droplets of the aerosol fall on the walls of the spacer. . Which of the following measures should the nurse implement to prevent pneumonia in the intubated client? Incorrect: Aspiration pneumonia can be prevented by inflating the endotracheal or tracheostomy cuff before feeding. a deep breath should be taken while releasing a puff of medication into the spacer. The spacer itself does not determine the dose to be given.Correct: Clients with Cushing's syndrome are at increased risk for infection because cortisol excess results in decreased lymphocytes and cell-mediated immunity. Control fluid volume deficit Prevent infection Promote weight gain Restrict activity 45 A client with COPD is prescribed to take ipratropium (Atrovent) via a metered-dose inhaler with spacer. Visitation is often limited in this environment to promote rest for the acutely ill client. the goal is to maintain the client's current activity level and gradually increase activity tolerance. and finer droplets disperse more fully within the spacer and can be delivered deeper into the airways. The client asks the nurse why the spacer is necessary. 46 A client is on ventilatory assistance in the intensive care unit. Rather. Recall that this syndrome involves an excess of cortisol that has mineralocorticoid activity resulting in excessive retention of sodium and water. and altered antibody activity.
pulmonary function tests Electrocardiogram. limit carbohydrates and fats to reduce excretory demands. a diet low in potassium is recommended.Correct: A key goal of the diet for clients with chronic renal failure is reducing the quantity of metabolic waste that requires excretion by the kidney (i.5 g/kg of ideal body weight. Use clean technique when suctioning. and by changing respiratory equipment every 24 hours. protein intake is restricted to 1-1. and salt substitutes. This includes reducing intake of foods high in potassium such as citrus fruits. green leafy vegetables. increase the intake of foods high in potassium to promote electrolyte balance. Restrict family visitation to once per shift. One method to diminish the risk is to drain condensation in the ventilator equipment into the designated reservoir. BUN/creatinine Chest x-ray.e. protein). 47 Data related to which of the following assessments would be essential prior to administration of an aminoglycoside. coagulation studies Serum electrolytes. Therefore. using cautiously in clients with impaired renal functionincluding the elderly-and keeping clients well hydrated. too many calories can place an increased excretory demand on the kidney. Maintain cuff deflation at all times. However.Incorrect: There are not serious pulmonary side effects to this category of drugs. NOT back into the liquid reservoir. the essential baseline data should be direct tests of renal function such as BUN and creatinine. This is sufficient to promote healing but also limits excretory demands on the kidney. Risks of kidney damage can be minimized by detecting early signs of renal impairment. Audiometry.Incorrect: Although sufficient calories are required for growth and repair of the kidney.Correct: Individuals requiring mechanical ventilation for 48 hours or more have a 10% to 20% chance of developing pneumonia.visitors should be screened for colds/flu that may be transmitted to the client and staff.Incorrect: The aminoglycosides are not known to cause cardiac or coagulation problems. one of the goals of diet therapy is to: Incorrect: Because potassium retention occurs in chronic renal failure due to reduction in the nephrons excretory ability. arterial blood gases 48 For the client with chronic renal failure. all tracheostomy and endotracheal airways should be managed using sterile technique. The most serious adverse reaction is nephrotoxicity.Incorrect: In the hospital environment. such as Gentamicin? Correct: Because aminoglycosides are nephrotoxic and ototoxic. . Drain tube condensation into the external reservoir.Incorrect: Ample calories are required for growth and repair and should be obtained from carbohydrates and fats because they do not require renal excretion of metabolic by-products. laboratory reports of renal function and hearing are essential baseline data.Incorrect: Serum electrolytes and acidbase balance may be altered in the client who receives an aminoglycoside and experiences nephrotoxicity.
sedatives. and diuretics. oxygen is temporarily discontinued. Diet has not been implicated in the etiology of incontinence.Incorrect: The best position to facilitate removal of pleural fluid is to have the client lean over the bedside table with the head and crossed arms resting on several pillows. sneezing. it is essential that an ophthalmologist evaluate the client's . such as hypnotics. coughing. and the feet supported by a footstool.Correct: Stress incontinence involves a loss of 50 ml or less of urine following an activity that increases intraabdominal pressure on the bladder such as lifting. 49 A client is scheduled to have a thoracentesis to remove excessive pleural fluid.Incorrect: Supplemental oxygen should NOT be discontinued during the procedure especially in the client who is having difficulty breathing. sedation is not administered since the cooperation of the client is essential. a sedative will be given prior to the exam. Which intervention should be included in those plans? Incorrect: Irrigation with copious amounts of a nontoxic solution such as water or saline would be appropriate if the visible foreign object was a loose substance such as dirt or an insect. 50 During a health assessment of a post-menopausal female. tranquilizers. or laughing. Which additional information should the nurse gather? Incorrect: Alcohol generally acts as a diuretic and increases urine output.Incorrect: Stress incontinence is seen primarily in women who have relaxed pelvic muscles. coughing should be avoided during the procedure." The nurse suspects stress incontinence. Alcohol consumption Current medications Diet history Precipitating factors 51 An emergency room nurse is asked to develop a plan of care for clients who experience eye trauma.Correct: Coughing is also avoided during the procedure to avoid damage to the pleura of the lung. In the case of an embedded or penetrating object. restrict protein intake to decrease metabolic waste.maximize caloric intake to promote healing. The exact nature of alcohol consumption is not relevant to the incidence of stress incontinence. the nurse documents the client's complaint that she "frequently loses urine. are contributing factors to “urge” incontinence.Incorrect: Medications. Therefore. or if the client sustained a chemical burn to the eye. positioning will involve lying on the affected side. The nurse helps prepare the client for this procedure by explaining that: Incorrect: During a thoracentesis it is important to emphasize to the client the importance of NOT moving during the procedure to avoid damage to the pleura and lung.
The eye should be protected with a shield such as a paper cup.Incorrect: The prokinetic agents (i.Correct: Omeprazole (Prilosec) is classified as a proton pump inhibitor and acts by inhibiting gastric parietal cells and suppressing gastric acid secretion by more than 90%. 53 The nurse is conducting a stop smoking clinic and includes a discussion of laryngeal cancer.Correct: Chronic hoarseness.Incorrect: Enlarged cervical lymph nodes are considered late manifestations of laryngeal cancer as a result of metastases. Cover the injured eye immediately with a pressure dressing. and medical assistance obtained. in which case flushing with saline irrigations is begun immediately. the uninjured eye should be covered to prevent excess movement of the injured eye.Correct: It is important to establish a baseline and evaluate vision before initiating treatment (as well as after). Briefly assess visual acuity prior to treatment. This is often associated with dysphagia. airway obstruction. Blindness could occur if the injury is mistreated.e. especially in an individual who smokes is the most common presenting symptoms of laryngeal cancer. neutralizing gastric acid. early symptom of laryngeal cancer is: Incorrect: Signs of metastases of laryngeal cancer to other parts of the larynx include pain in the Adam's apple that radiates to the ear. 54 .eye before any treatment is initiated. pain in the ear. enhancing GI motility. both eyes are patched. If treatment is initiated when hoarseness first appears a cure is usually possible. The histamine (H2) receptor antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) also reduce gastric acid secretion. The exception is chemical burns to the eye. suppressing gastric acid secretion. enlarged cervical nodes. Gently remove any penetrating objects.Incorrect: Antacids are given to neutralize gastric acids or buffer it's effects.Incorrect: Penetrating objects should not be removed. Propulsid) increase strength of esophageal peristalsis and increase lower esophageal sphincter pressure to prevent reflux. increasing lower esophageal sphincter pressure. Participants should be informed that a classic. This drug acts primarily by: Incorrect: The prokinetic agents such as cisapride (Propulsid) act by enhancing GI motility.Incorrect: To avoid further trauma. the physician has prescribed omeprazole (Prilosec). Immediately irrigate all injuries with a saline solution. chronic hoarseness. 52 As part of the treatment plan for the client with gastroesophageal reflux disease (GERD).Incorrect: Airway obstruction is a sign of advanced laryngeal cancer. A pressure dressing is avoided to prevent further trauma.
wrist and vertebrae. These symptoms may be side effects of other drugs such as diuretics. The clinical expression of post-menopausal osteoporosis may be the “dowager hump” and reduced height. many other conditions may cause anorexia and nausea.Incorrect: A limitation in range of motion of the elbow and knee joints is most likely related to the pain associated with arthritic changes. and impaired flow of cerebral spinal fluid .Correct: Electrolyte imbalances such as hypokalemia. the nurse should give high priority to assessing for digoxin toxicity when: Incorrect: These GI effects commonly occur with digoxin therapy. Opioids are not known to enhance digoxin toxicity. bradycardia may indicate digoxin toxicity. The most common electrolyte disturbance is hypokalemia because potassium-losing diuretics are often given concurrently with digitalis preparations in the treatment of congestive heart failure. 56 Increased intracranial pressure (ICP) can occur due to a variety of diseases or injuries. The risk of fracture is caused by the bone fragility.Correct: Osteoporosis is a common age-related metabolic bone disease in which there is reduced skeletal bone mass. or nifedipine can contribute to digoxin toxicity. and hypercalcemia are known factors in promoting digoxin toxicity. Which physical assessment finding is an early sign of ICP in a client with a head injury? Correct: Increased intracranial pressure (ICP) is the pressure exerted in the cranium by the pressure of blood. pulse rate drops from 90 to 68 bpm.Incorrect: Digoxin has a low therapeutic index. Concurrent treatment with other drugs affecting the heart. edema. Although the presence of these symptoms raises suspicion of digitalis toxicity. However.The nurse who provides health care maintenance care to a group of elderly women in a low-income apartment setting recognizes which assessment sign is related to the presence of osteoporosis in this population? Incorrect: The loss of appetite and muscle tissue wasting can occur in many disease states or use of various types of medications. The priority assessment indicator is hypokalemia.Incorrect: The desired effects of digoxin therapy are: a reduction in heart rate (negative chronotropic effect). hypomagnesemia. serum potassium falls.Incorrect: An unstable gait and frequent falls signal neurological disease or stroke. anorexia and nausea occur. verapamil. such as quinidine. Hypokalemia increases cardiac excitability and increases the risk of digoxin toxicity. especially in the hip. given concurrently with opioids. and an increase in myocardial contractility (positive ionotropic effect). Osteoporosis is a condition in which bone demineralization causes a reduction in bone density and mass. Loss of appetite and wasting of muscle tissue Loss of height and a "humped" appearance to the upper back Inability to straighten the elbows and knees Unstable gait and frequent falls 55 In the client who is receiving a combination of furosemide and digoxin.
) The first and most sensitive indicators of ICP are the subtle changes in orientation and level of consciousness. The primary reason this position is important is because it: Correct: This position prevents venous pooling in the hand and forearm by increasing venous return. promoting lymphatic flow.a desired goal in the management of lymphedema following radical mastectomy. Sluggish papillary reactions or blurred vision occur in the earlier response to ICP. the most important goal or outcome is to ensure urinary elimination by measuring I & O.Incorrect: A sign that a client has developed ICP in an advanced phase is decreased motor activity or paralysis. Pain or renal colic is the primary symptom in an acute episode of renal calculi. the most appropriate outcome would be to expect the client to: Incorrect: Clients with renal stones typically are not febrile. preventing a 'frozen shoulder' from lack of normal movement. Performance of arm exercises helps restore full range of motion to the arm and shoulder. lymphedema can occur and lead to infection.Incorrect: The nurse may assess bradycardia and irregular respiratory pattern (Cheyenne Stokes) in the client in the later phases of increased intracranial pressure. Change in orientation and level of consciousness Bradycardia and tachypnea Fixed and dilated pupils Decreased motor activity or paralysis 57 Following a left.Correct: Because stones can obstruct the ureters. Clients must be taught how to prevent lymphedema through positioning and exercise. the reason the arm is elevated is to promote lymphatic drainage. radical mastectomy the nurse assesses the wound and positions the left arm on pillows so that the hand is higher than the elbow and the elbow is higher than the shoulder.Incorrect: Although this position may enhance comfort. prevents shoulder subluxation. the presence of renal calculi can lead to an increased risk for infection in susceptible individuals. 58 In planning care for the client with renal calculi. and prevent lymphedema.Incorrect: Elevating the arm would increase venous return . Hematuria may be present if the stone has rough edges. and decreased score on the Glasgow Coma Scale. irritability. reduces pain.(obstruction or infection.Incorrect: The client may or may not need to acidify the . enhances lymphatic drainage. In the client who had a large number of lymph nodes dissected.Incorrect: The nurse may assess pupils that are fixed and dilated in the client experiencing the later phase of ICP. decreases venous return. Behavioral changes may include: restlessness. However. However. confusion. Adequate hydration involves at least 2500 mL/day or more to help prevent urinary stasis that can lead to stone formation and UTI.Incorrect: An intake of 1000 mL daily is too low.Incorrect: Shoulder problems can occur if the client does not adhere to the prescribed exercise regimen. the primary reason for keeping the affected arm elevated is to promote lymphatic flow.
a 24-hour urine collection is performed to determine urine pH and elements such as calcium. and hypotension. phosphate calculi develop in alkaline urine. pressure-related skin injury.Incorrect: The elevation of the foot of the bed may be used at times for counter traction. maintain urine output equal to intake.Incorrect: Dyspnea. To facilitate treatment. headache. wheezing and hypotension. therefore prevention depends on keeping the urine acidic.urine based on the mineral composition of the stones. flushing.Incorrect: The client is encouraged to move the unaffected extremities to reduce the risk of fat embolism syndrome. and urticaria are typically symptoms of a mild allergic reaction to transfusion therapy caused by sensitivity of the recipient to foreign plasma proteins. and uric acid levels. and hypertension. sudden onset of chills and fever. Head of the bed is elevated Foot of the bed is elevated Weights are not hanging freely Client is moving the unaffected leg 60 While a client is receiving a blood transfusion. For effective use of traction. Which finding indicates a need to notify the client's nurse? Incorrect: As long as traction is maintained. wheezing. the nurse needs to closely monitor the: . itching. the head of the bed may be elevated. the nurse continually assesses for the most common symptoms of a nonhemolytic transfusion reaction. urticaria.Correct: Russell's traction is a modification of Buck's traction. or plasma. flushing and anxiety. This type of reaction occurs when the recipient becomes sensitized to the donor's WBC. jugular vein distention. itching.Incorrect: Urticaria. phosphorus. platelets. jugular vein distention. demonstrate a reduction in fever. and urticaria. it is essential that the weights are hanging freely.Incorrect: Flushing. nonhemolytic transfusion reaction are sudden chills and fever. 59 The nurse teaches nursing assistants to recognize and notify the nurse when traction is interrupted for clients in Russell's traction. dyspnea. 61 Immediately following the application of a cast to a client's fractured forearm. This type of traction adds a vertical pull by placing a sling under the leg above the knee. verbalize ways to acidify the urine. uric acid stones tend to develop in acidic urine. and signs of shock are clinical manifestations of an anaphylactic reaction to blood components. and muscle soreness. On the other hand. consume at least 1000 mL of fluids/day. therefore alkalinizing the urine is helpful. chest tightness. These symptoms include: Correct: The characteristic symptoms of a febrile. and hypertension are some of the signs/symptoms of circulatory overload that may occur if blood is given to rapidly or in the client with congestive heart or renal failure. For example.
Which of the following primary care provider orders should the nurse question? . or 4) promotion of healing. however.Incorrect. The cranial nerve exam is performed in the assessment of the components: papillary response. blink and gag reflexes. subtle changes in level of consciousness usually precedes alterations in cardiorespiratory status. tracking. nutritional status of the client. swelling. but will require attention later. The assessment of the color. which allows for weight bearing and ambulation.Incorrect: The vital sign assessment may change (bradycardia. movement of distal fingers and toes. 63 An adult client with cirrhosis of the liver has developed ascites. 2) prevention or correction of a deformity.Incorrect: Measurement of the intake and output volumes is not priority care measures in the care of the client with a suspected intracranial hemorrhage. movement of distal fingers and toes. The components of the scale includes: eye. swelling. Observe for signs of bleeding form the ears. The psychosocial response to injury is not a priority for the care of a client with a newly applied cast. motor and verbal response. facial muscles. client's psychosocial response to injury. client's airway and breathing. and sensation indicates adequacy of the neurovascular status of the extremity.Incorrect. pulses distal to cast. extra-ocular movements. pulses distal to cast. and sensation indicates adequacy of the neurovascular status of the extremity. Make frequent neurological assessments. The assessment of the color. 62 A client arrives in the emergency department with an acute head injury suspected to be an intracranial hemorrhage. Thorough assessment and prompt intervention are essential to prevent cast-related complications. Nutritional status is not a priority for nursing care at the time of cast application. The serum sodium is 145 mEq/L and potassium is 3.Incorrect: There may not be any external signs of bleeding with an acute head injury. 3) bone realignment. speech patterns. Measure the client's intake and output. and sensation indicates adequacy of the neurovascular status of the extremity. A cast is a temporary device used for: 1) immobilization. swelling. movement of distal fingers and toes.2 mEq/L.Incorrect. The neurologic assessment (Glasgow Coma Scale) provides more data regarding the status of the client with acute head injury. Monitor the client's vital signs frequently. no information is presented in the stem to suggest that the airway or breathing has been compromised at the time of the cast application.Correct. neurovascular status of the injured arm. Although management of the airway and breathing are always the priority for care. The assessment of the color. pulses distal to cast. increased systolic blood pressure and widened pulse pressure). The nurse includes which intervention as a priority in the plan for care? Correct: The neurologic assessment (Glasgow Coma Scale) provides more data regarding the status of the client with acute head injury. and any other pertinent neurologic findings. abnormal respiratory pattern.
Incorrect: It would be inappropriate to delay reporting this finding to the surgeon since the yellow drainage may indicate leakage of CSF. remove the dressing and assess the incision. report this finding immediately to the surgeon.Incorrect: Although sodium restriction is often based on a 24-hour urine collection to determine sodium loss. sodium is generally restricted to 1 g (1000 mg) daily for clients with ascites. A restriction of 1500 ml/24 hours is reasonable for the dilutional effect. I'm afraid to go back to work or see my friends anymore. outline the drainage area and reassess in one hour.Incorrect: If bedrest and sodium restriction do not improve ascites. 1000 mg of sodium per day. document. A severe fluid restriction. "I'm constantly worried that I'll have a seizure and lose control. Yellow drainage could signal a CSF leak and should be immediately reported.Correct: Surgeons generally have individual preferences regarding changing head dressings. Although thiazide diuretics may be used. a client diagnosed with epilepsy verbalizes to the nurse. coupled with diuretic therapy could lead to decreased output and renal failure. In this case. Assessing the incision would not provide a further data regarding the yellow drainage.Incorrect: Fluids are restricted if hyponatremia is caused by fluid retention. the nurse observes yellowish drainage on the dressing. and continue to observe. The presence of yellow drainage on a head dressing signals a possible CSF leak and should be immediately reported. The nurse should: Incorrect: Yellowish drainage should be immediately reported to the surgeon because it may indicate a cerebrospinal fluid (CSF) leak. reinforce the dressing. diuretics may be used. the nurse should mark the drainage area with a pen in order to determine additional drainage at a later assessment. Dressing reinforcement is generally appropriate when excessive drainage is expected and the original dressing is not to be removed.9% sodium chloride would be contraindicated in the client who is retaining sodium and water.9% NaCl to infuse IV at 50 cc/hr 1500 mL/24 hour fluid restriction Spironolactone 25 mg bid 64 While conducting an assessment for a client following a craniotomy. Spironolactone (aldactone) is often the first diuretic chosen because it promotes potassium retention.Correct: An intravenous infusion of 0. a common finding in clients with cirrhosis because aldosterone metabolism is impaired.Incorrect: Surgeons generally have individual preferences regarding changing head dressings. Assessing the incision would not provide a further data regarding the yellow drainage. 65 During a follow-up assessment after discharge from the hospital. This order should be questioned by the nurse. Note the client's K+ level is low. it would be important to evaluate the extent of drainage over time by marking the area on the original dressing and continue to observe. After notifying the surgeon. they may worsen hypokalemia." Which is the most appropriate nursing diagnosis for this client? Incorrect: The nursing diagnosis 'ineffective management of the therapeutic . 0.
In addition. Ineffective management of therapeutic regimen Impaired verbal communication Risk for injury due to seizures Self-concept disturbance related to diagnosis of epilepsy 66 A client diagnosed with acute pancreatitis has a history of alcoholism and opioid abuse. Nurses often fear giving prescribed analgesics will increase addiction and therefore under-medicate the client. The client should receive pain medication for only as long as s/he requires it. Which intervention is indicated for the care of the client? Correct: The nurse should administer morphine.Correct: The nursing diagnosis “self esteem disturbance related to the diagnosis of epilepsy” relates to the client's feelings and perceptions of self that has occurred as a result of the change in health status.Incorrect: The calcium channel blockers do not have any diuretic effect. This situation pertains to the client's response to the condition and perceived self-concept as a result. it is common for the drug-addicted individual to require higher doses of analgesics than the average person. especially when the request for the analgesic is within the prescribed time frame.Incorrect: Placebos are unethical unless part of a research protocol where client consent has been obtained. Many clients who are diagnosed with epilepsy fear the onset of a seizure in a public setting. Withhold the drug for another hour. which of the following desired outcomes does the nurse expect? Correct: Through coronary vasodilation. Keeping the client in pain may actually contribute to a relapse of the addiction. Three hours after an initial dose the client is crying and asking for more morphine. Give a saline placebo.Incorrect: The nursing diagnosis “risk for injury due to seizures” relates to the physical risk of injury during a seizure event. Morphine 10-15 mg IV prn q 3-4 hours is ordered. 67 After administering a calcium channel blocker.Incorrect: Calcium channel blockers such as verapamil cause systemic vasodilation resulting in decreased blood pressure.Incorrect: Although nonpharmacological strategies are effective in diminishing the perception of pain.Incorrect: Again. The client with epilepsy does not experience impairment to the language center except during the seizure event. It .Incorrect: The nursing diagnosis “impaired verbal communication” relates to the expressive or receptive aspects of language. Administer morphine 15 mg as prescribed.regimen” relates to the medication schedule and therapeutic drug levels and not the client's self-concept or adaptation to the illness. medication should not be withheld. calcium channel blockers result in decreased frequency and severity of anginal attacks. the client should not be penalized by withholding pain medication. Substitute distraction techniques for opioid administration.
stage 3 adenocarcinoma. This is characteristic of grade 1 lesions. and seizures. risk for injury is high.Incorrect: Although this nursing diagnosis is extremely relevant to the care of clients with Alzheimer's disease. Agents prescribed for intermittent claudication. While it is important for the nurse to minimize the impact of social isolation. 69 The biopsy report for the client after a colon resection indicates a grade 3. impaired judgment.Incorrect: Benign neoplasms are often encapsulated and therefore have limited growth potential. clients may feel anxious and frustrated as they realize cognitive changes are occurring.Incorrect: Neoplasms that are localized without spread to adjacent tissue or other organs are classified as stage 2 lesions. . inability to make decisions. matters of safety take priority. social isolation due to diminishing social relationships.Incorrect: The cognitive and biochemical changes in Alzheimer's disease affect personality and behavior. and that the diagnosis of altered thought processes is indeed a priority. One could argue that altered thought processes are the etiology of risk for injury. Stage 3 lesions involve extensive local and regional spread.Incorrect: In the early stages of Alzheimer's disease when memory and cognitive impairments are mild. the client may feel alienated and powerless to do anything about it. Loss of differentiation means a higher degree of malignancy.Incorrect: Although calcium channel blockers have a vasodilating effect.Incorrect: Well-differentiated neoplasms retain characteristics similar to the parent tissue and therefore are less invasive. they are not known to relieve the pain associated with arterial occlusion. the plan of care for the diagnosis of altered thought processes focuses primarily on promoting effective communication and reality orientation. Because clients with Alzheimer's disease are prone to wandering.should be noted that these agents are contraindicated in clients with congestive heart failure since they may reduce contractility and cardiac output. As social interactions decrease. confusion. In planning care for this client. and decreased attention span all contribute to the risk for injury. The client may begin to withdraw from friends and social events as memory impairments and personality changes become more apparent. the priority care concern is safety. anxiety due to perceived powerlessness. Memory loss. Decreased frequency and severity of angina Increased blood pressure Reduction in peripheral edema Relief of intermittent claudication 68 The nurse supervising care of clients with Alzheimer's disease in an adult day care identifies which of the following as the priority nursing diagnosis: Correct: The client's safety is always paramount to the plan of care. altered thought processes due to dementia. agitation. However. safety due to memory loss and impaired judgment. the nurse understands that the tumor: Correct: Grade 3 neoplasms are poorly differentiated (extensive structural changes from tissue of origin). such as pentoxifylline (Trental) improve blood flow by decreasing blood viscosity rather than by vasodilation.
nausea. Bowel sounds may be decreased or absent and anorexia. which is the most likely cause of the client's symptoms? Incorrect: Cholecystitis is characterized by sudden onset of pain in the RUQ that often radiates to the right scapula or shoulder.Incorrect: Passive natural immunity is acquired when antibodies are transferred naturally from an immune mother to her baby through the placenta or in colostrum. and possibly vomiting may be present. 70 The nurse administers the MMR vaccine to a child in the health clinic. Clients with ulcerative colitis often experience profuse diarrhea (15-20 stools per day) containing a mixture of blood.Incorrect: Passive artificial immunity is acquired by administering an antibody from an animal or another human. Significant losses of fluids and .Correct: One of the distinguishing clinical manifestations between Crohn's disease and ulcerative colitis is bloody diarrhea. or the mumps. fewer in number (3-5/day). semisolid. symptoms of Crohn's disease differ from ulcerative colitis in that stools are large.Incorrect: Crohn's disease and ulcerative colitis are classified as inflammatory bowel disease.Incorrect: Active natural immunity is acquired by the body's own efforts to form antibodies in the presence of active infection. nausea and vomiting. Although anorexia and weight loss often occur in both types of inflammatory bowel disease. colicky abdominal pain or localized pain in the right lower quadrant is characteristic of Crohn's disease. or administration of tetanus immune globulin for prophylaxis against tetanus. Symptoms may resemble those of appendicitis. and possibly pus. An example is the individual who has had any of the childhood diseases such as chickenpox. low-grade fever (a classic sign). Which type of immunity will this child possess? Correct: Active artificial immunity is acquired through administration of antigens (vaccines or toxoids) to stimulate antibody production. was confined to the intestinal wall. Based on this data.has metastasized to regional tissue. Active artificial immunity Active natural immunity Passive artificial immunity Passive natural immunity 71 A 32-year-old female complains of having 10-12 diarrhea stools per day that contain bloody mucus and left-sided abdominal cramping prior to each stool. and rarely contain blood. Diffuse. was encapsulated and completely removed. measles. and may be associated with eating a large or fatty meal. Left-sided abdominal cramping can be present prior to the bowel movement and is relieved by emptying the bowel. feeling of bloating. An example is administration of immune globulin to the person exposed to hepatitis B. is similar to normal tissue and slow growing.Incorrect: The clinical manifestations of diverticulitis include crampy lower left quadrant pain. She states she has little desire to eat and has lost approximately 10 pounds in the last 2 weeks. mucus.
The . Preventing spread of infection must include enteric precautions (wearing gloves when handling feces/urine). it is not a reliable indicator since pallor may be difficult to determine in clients with darker skin tones. Color changes must be assessed in a variety of places such as buccal mucosa. and palate based on underlying skin tones. Enteric precautions Private room Wearing gloves when handling blood Contact precautions 74 Which assessment data is essential to evaluate the effectiveness of oxygen therapy? Incorrect: Although the carbon dioxide level in arterial would be helpful information in evaluating the client's gas exchange and overall oxygenation status. often through food contaminated by infected food handlers. Cholecystitis Crohn's disease Diverticulitis Ulcerative colitis 72 A client inadvertently takes too many Coumadin tablets.Incorrect: Naloxone is the antidote for opioid analgesics. The PCO2 is a measurement of ventilation but is most essential in evaluating acid-base status since the PCO2 is the respiratory component in acid-base determinations. Acetyocysteine Naloxone Protamine sulfate Vitamin K 73 The nurse is planning care for a client with hepatitis A. Contact precautions would be appropriate with hepatitis A in the client who is diapered or incontinent. confusion.Incorrect: Protamine sulfate is the antidote for heparin.Incorrect: A private room is necessary only if the client cannot implement self-care measures for disposal of feces and urine (i. incontinence).Incorrect: Hepatitis B virus is transmitted through blood and body fluids.Incorrect: Although skin color is an important component in assessing tissue oxygenation. Which intervention would most effectively achieve this goal? Correct: Hepatitis A virus is transmitted by the fecal-oral route. The nurse includes measures to prevent secondary transmission of the virus. The nurse anticipates the practitioner will order which of the following as an antidote? Incorrect: Acetyocysteine is the antidote for acetaminophen.Incorrect: Contact precautions are used for clients known to have diseases easily transmitted by direct client contact. it is not essential in evaluating O2 therapy. nail beds. conjunctiva.e.Correct: Vitamin K is the antidote for warfarin (Coumadin).electrolytes can occur as well as weight loss. lips.Correct: Either the PO2 or the oxygen saturation gives the most accurate information about arterial oxygenation. The same is true in assessing cyanosis.
the most likely intervention would be to increase the heparin infusion rate. the client is given nothing by mouth. Pulse oximetry is a common method of measuring O2 saturation. Repeat the APTT before any other action. Which intervention should the nurse anticipate? Incorrect: The APTT value is at the low end of therapeutic range.e.Incorrect: In preparation for possible surgery. The APTT value indicates the need for increasing the heparin rate to enhance therapeutic drug levels. approximately every 6 hours). Therefore. However.Correct: The normal control value for the activated partial thromboplastin time (APTT) is 25-35 seconds. pain medication is usually withheld until a definite diagnosis of appendicitis has been made. Maintain current heparin therapy. During heparin therapy. 76 A nurse is observing a client who is being evaluated for possible appendicitis. the client's hemoglobin level does not provide data about the effectiveness of oxygen therapy. A standard protocol calls for administration of a continuous infusion of heparin for at least 5 days.Incorrect: Heat should be avoided because the increased circulation to the appendix can lead to rupture. Thus. If the APTT value were extremely low or high a repeat value would be recommended. Since the partial pressure of oxygen (PO2) is the driving force behind O2 saturation.PO2 is an indirect measure of O2 content of arterial blood. both are useful in evaluating the effectiveness of O2 therapy. which intervention is appropriate? Incorrect: Enemas or laxatives may increase peristalsis and cause the appendix to rupture.5 times the control. Discontinue drug therapy. therapeutic values are 35-85 seconds.Correct: To avoid masking critical changes in symptoms.Incorrect: Although the APTT is closely monitored throughout heparin therapy (i. During heparin therapy. the APTT should be maintained at about 1. In addition. O2 saturation is an indication of the percentage of hemoglobin saturated with O2.5 to 2.Incorrect: Hemoglobin levels are essential to maximize the blood's oxygencarrying capacity since oxygen attaches to the hemoglobin molecule.5 to 2. This client's APTT is at the low end of the therapeutic value. the APTT should be maintained at about 1. there is no indication in this case for repeating the APTT before action can be taken.Incorrect: The normal control value for the activated partial thromboplastin time (APTT) is 25-35 seconds. the client has only been receiving heparin therapy for two days. Increase the heparin infusion rate. Arterial CO2 level Skin color Oxygen saturation Hemoglobin level 75 A client with a deep vein thrombosis has been receiving heparin therapy for two days. Cleansing the GI tract with saline enemas in preparation for surgery Withholding analgesics until a diagnosis is established .5 times the control. Therefore. During the diagnostic period. The morning APTT is 40 seconds. therapeutic values are 3585 seconds.
Incorrect: Incorporating the client's circadian rhythms into the bowel management program may be helpful in promoting defecation at a regular time. Sufficient fluid intake.Incorrect: This age group is not considered by the ACIP as a high-risk group. Enemas and harsh laxatives are avoided to prevent diarrhea and fluid and electrolytes imbalances." "I have increased the fiber in my diet. which of the following groups should be included because they are considered at high risk for flu and respiratory complications? Correct: The Advisory Committee for Immunization Practices (ACIP) recommends immunization against influenza for all persons at increased risk of adverse consequences from infection of the lower respiratory tract. every day. Fiber without adequate fluid can aggravate bowel function. The nurse realizes the first priority should be to: Correct: Esophageal varices can easily rupture causing excessive bleeding." 78 When planning an influenza immunization clinic. at least two liters daily. fiber laxatives.Incorrect: The client learned this concept well. and all health care workers. Which statement by the client indicates to the nurse that further teaching regarding bowel training is needed? Correct: If a client indicates s/he frequently uses an enema more teaching is required.m." "I am drinking between six and eight glasses of fluid a day.Applying heat to the right lower quadrant to promote comfort Restricting the client to clear liquids to reduce nausea 77 The home health nurse is working with a client who is in the convalescent phase after a cerebrovascular accident. and suppositories is generally implemented to support bowel regularity. "I find I need an enema almost every day. A well-balanced diet high in fiber stimulates peristalsis. This would include all persons older than 65 years of age.Incorrect: This age group is not considered in a high-risk category for serious consequences from infection of the lower respiratory tract.Incorrect: The client is adhering to an important aspect of bowel management.Incorrect: Children in general are not considered at high risk unless they have an underlying medical condition that places them at risk for adverse consequences from influenza. is necessary to maintain bowel patterns and promote proper stool consistency. . A bowel program of stool softeners. Elderly residents of long term or chronic care facilities College students in athletic training season Children that spend 3 days a week or more in day care High school students who ride the bus to school 79 A client with a known history of alcoholism presents to the emergency department disoriented to time and place and vomiting dark emesis. infants and children more than 6 months of age who are at increased risk for complications of influenza because of underlying medical conditions." "My care taker helps me use the toilet at 2 p.
urethral discharge. muscle tone diminishes. and weight loss Dysuria. an opportunistic disease. 80 A 55-year-old male suspected of having prostate cancer is admitted to the hospital. a common inflammatory process most often caused by an ascending infection via the ejaculatory duct through the vas deferens into the epididymis. and symptoms of UTI. As a result. However.Incorrect: Checking prothrombin time would be important for monitoring the client's bleeding potential. the priority intervention when bleeding is evident is to assess the client's hemodynamic status which includes pulse and blood pressure. and urinary stasis creates a fertile medium for bacterial growth and infection. and thrombocytopenia. Hematuria. however it would not be the first priority in the client exhibiting disorientation and dark emesis. Back pain. bilateral flank pain.Incorrect: These are common clinical manifestations of epididymitis. and pyuria is characteristic of adult polycystic kidney disease. fever. The client's disorientation and dark emesis suggest bleeding therefore assessment of vital signs is the first priority to evaluate hemostasis. retention. fatigue. Signs/symptoms of testicular cancer are often subtle until the person notices a feeling of heaviness in the lower abdomen and groin. nocturia. decreased vision and blindness are symptoms of . hematuria. Gastric lavage and/or pharmacologic therapy using vasopressin may be tried initially. fever. obtain a stool specimen for guaiac. and cyst infections. and back pain. the bladder wall changes in contour creating pockets for urinary retention. urgency. Consequently the bladder has less capacity. is an early indication of human immunodeficiency virus (HIV) disease? Incorrect: Floaters. and shock. A painless lump or swelling may be present. Other nonspecific symptoms include weight loss. Symptoms include urinary hesitancy. bilateral flank pain. assess pulse and blood pressure. impaired production of clotting factors. frequency. nocturia.Incorrect: Testing stool for blood is an appropriate assessment choice. and retention. painless testicular swelling.Incorrect: A combination of hematuria.Correct: When the enlarged prostate gland impinges on the urethra.Incorrect: Although esophageal tamponade may be required. Which symptoms would be consistent with this diagnosis? Incorrect: These are clinical manifestations of testicular cancer. Cysts are usually bilateral and diffusely scattered throughout the renal parenchyma causing pain. obstruction of urinary flow occurs. and pyuria Scrotal pain and swelling. and the bladder cannot empty completely at each voiding. prepare the client for esophageal tamponade. perform phlebotomy to check prothrombin time. hematuria. dysuria. other treatment measures are indicated especially if severe hemorrhage is not present. difficulty starting the stream. which is often increased due to poor vitamin K absorption. urgency. and low-grade fever 81 Which symptom of Candida albicans.hypovolemia.
This disease is not associated with chemical or metabolic degeneration as there is in rheumatoid arthritis. decreased vision. redness. and chronic cough Whitish-yellow patches in the mouth 82 Assessing a client with osteoarthritis. tendons. morning stiffness and fever. inflammatory connective tissue disorder. progressive. the client experiences fever and chills. night sweats. During the acute onset of rheumatoid arthritis. Floaters. pain and swelling of the joints. pain upon movement of the involved joints. This systemic disease affects all connective tissue. warmth and swelling to the joints. swollen joints that are warm to the touch.Incorrect: Rheumatoid arthritis is a chronic.Cytomegalovirus (CMV) retinitis. This secondary fungal infection. thrives in a warm. muscles. systemic. moist environment. pleura or blood vessels. The opportunistic infection occurs frequently in the immunocompromised host. This systemic disease affects all connective tissue. including the collagen of the heart. muscles. As the disease destroys the joints. Pain upon movement of the involved joints accompanies osteoarthritis. such as the client with AIDS. The erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) are usually elevated during the acute and chronic states of rheumatoid arthritis.Correct: Osteoarthritis is a non-inflammatory joint disease characterized by degeneration and loss of articular cartilage in synovial joints. tendons. vaginal or intestinal tract. inflammatory connective tissue disorder. morning stiffness may occur as an early symptom. stiffness. tendons. This is the most clinically significant type of infection in clients with HIV infection. and blindness Nodular lesions on the skin Fever. peripheral joints with symmetrical distribution. peripheral joints with symmetrical distribution. commonly caused by candida albicans. systemic. progressive. an elevated erythrocyte sedimentation rate (ESR).Incorrect: Fever. It affects primarily the small. pleura or blood vessels. the client experiences pain. pleura or blood vessels. 83 A nurse has reviewed the cardiac enzyme studies of a client with unstable angina .Incorrect: Rheumatoid arthritis (RA) is a chronic. It affects primarily the small. systemic. peripheral joints with symmetrical distribution. It affects primarily the small. muscles. progressive. inflammatory connective tissue disorder. reddened. night sweats and chronic cough are symptoms of Pneumocystis carinii pneumonia.Correct: Whitish-yellow patches in the mouth are characteristic of candidiasis. such as the mucous membranes of the mouth. This common assessment finding is evident on the external skin surfaces. This respiratory complication is the most common life-threatening infection in clients with AIDS.Incorrect: Nodular lesions of the skin are likely to be Kaposis sarcoma. This systemic disease affects all connective tissue. When RA develops insidiously. including the collagen of the heart. including the collagen of the heart. the nurse recognizes that the most common clinical manifestation of the disease is: Incorrect: Rheumatoid arthritis (RA) is a chronic.
The client informs the nurse that today the fluid returning after the instillation of the dialysate was cloudy. inadequate fluid intake. resulting in hyperosmolar body fluid. successively low or high pressures would not tell the physician any direct information about myocardial cell injury or death. hemorrhage. water losses with diabetes insipidus. result in concentration of the solutes in the vascular space and hyperosmolarity. The vascular space becomes hyperosmolar.Incorrect: A stress test is an important diagnostic tool in clients with stable angina. 85 The nurse is caring for a male client who is using home peritoneal dialysis to manage chronic renal failure. severe vomiting and diarrhea.Correct: CK-MB is the isoenzyme specific to the myocardium and elevation begins within 4-8 hours after an acute MI. isoenzyme and troponin I levels 84 When assessing a client for fluid and electrolyte imbalances.Incorrect: Pure water losses. central venous pressure monitoring.Incorrect: Although vomiting and diarrhea usually result in fluid losses that are in proportion to electrolyte losses. a treadmill stress test. The nurse can anticipate that further diagnostic studies to help clarify the client's cardiac injury will be: Incorrect: Serial blood pressure readings provide important information in the diagnosis of hypertension. The client's creatine kinase (CK) is elevated. These losses occur in proportion to one another.Incorrect: Central venous pressure monitoring. although helpful in monitoring fluid status would not provide diagnostic information about the client's cardiac injury. Although the blood pressure is directly affected by myocardial damage if cardiac output is reduced.who was recently admitted to the cardiac care unit. therefore the loss is isotonic in nature. the nurse knows that a common cause of iso-osmolar fluid volume deficit (hypovolemia) is: Correct: Excess blood loss involves fluid and solute loss from the vascular space. This is usually a sign of: Incorrect: Displacement would likely result in little to no return of the dialysate.Incorrect: Peritoneal dialysis works on the principle of osmosis to cause movement of extra fluid from the client into the dialysate. severe vomiting and diarrhea cause a loss of body water greater than the loss of solutes such as electrolytes. serial blood pressure readings. Cardiac troponin has a high specificity for myocardial injury and rises earlier than CK-MG. A cloudy dialysate return should prompt the nurse to . Client's experiencing unstable angina would be at increased risk for an acute MI if subjected to exercise stress testing. This process should not alter the appearance of the dialysate. as occurs in diabetes insipidus.Incorrect: A decrease in water intake results in an increase in the number of solutes in body fluid. Both are important indicators of myocardial cell damage. Serial blood pressure readings are not used as a diagnostic tool to identify degree of myocardial injury and necrosis.
the ability to have an erection and to experience orgasm will gradually return following radical prostatectomy. the client scheduled for a radical prostatectomy asks the nurse how the surgery will affect sexual function. peritonitis. Peritonitis is recognized by a fever. which of the following set of signs/ symptoms. Clients with iron deficiency anemia often experience a generalized fatigue as related to diminished oxygen carrying capacity of the hemoglobin. peritonitis should be suspected. .consult the physician since peritonitis may be present. Any time the dialysate is cloudy in appearance. pallor. whether peritoneal or hemodialysis is to remove waste and toxic material from the body. weakness. if present. because the loss of the prostate gland interrupts the flow of semen and ejaculation will not occur. infection 87 During a counseling session. splenomegaly Easy bruising.Incorrect: The return of erectile capability may be delayed following total prostatectomy but the ability to have an erection will gradually return for most clients. petechiae. cloudy outflow of solution. exertional dyspnea and pallor. The hallmark of iron deficiency anemia is hypochromia.Correct: Peritonitis is a major threat during peritoneal dialysis. The presence of nitrogenous waste products in the dialysate will not alter the color or clarity of the solution. Hypotension. bright red tongue.Incorrect: These signs/ symptoms are indicative of hemolytic anemia often caused by drugs or an autoimmune response against the person's RBCs. However. It would be inappropriate to assure the client that sexual function will be completely normal. chills. which is small red blood cells that are devoid of pigment. the male will no longer be fertile. tachycardia Hypochromia. or may be found in clients with aplastic anemia along with the usual manifestations of anemia such as fatigue.Correct: Following any type of radical prostatectomy. would coincide with this diagnosis? Incorrect: These clinical manifestations are characteristic of anemia secondary to acute blood loss. inadequate iron intake or malabsorption. clients may be impotent for several months even after a nerve-sparing prostatectomy. excess nitrogenous wastes. displacement of the dialysis tube. 86 When assessing a client with iron deficiency anemia.Correct: These are the classic symptoms of iron deficiency anemia often associated with chronic blood loss. fluid volume deficit. abdominal tenderness or pain. The nurse's response should be based on that fact that: Incorrect: Although clients are not able to ejaculate. vomiting.Incorrect: The purpose of dialysis.Incorrect: Aside from fertility. fatigue Jaundice.Incorrect: These signs/symptoms correlate with disorders of coagulation such as hemophilia or thrombocytopenia. most aspects of sexual function will gradually return.
45% sodium chloride would be given to hydrate the cell and provide calories and sodium which has been lost. impotence is a permanent outcome. such as 3% or 5% sodium chloride. which is hypotonic.9% NaCl which is considered the isotonic standard (approximately equal to the sodium chloride concentration of the blood).Incorrect: An extremely hypertonic solution. which has been lowered by sodium and water losses from the severe diarrhea.Correct: Because the client is hypotensive. Blood pressure is 98/68. infertility will occur. This is best achieved by using an isotonic solution such as . respirations 20/minute. Hypotonic solutions cause water to move into the cell. all aspects of intercourse should return to normal.45% sodium chloride . The nurse closely monitors blood sugar throughout TPN therapy and the practitioner makes solution adjustments.Incorrect: The nurse's responsibility is to monitor for signs/symptoms of fluid and electrolyte imbalances and notify the physician who will make solution adjustments (i. 88 An adult client is admitted with dehydration caused by severe diarrhea. Discontinuation of TPN is done gradually to prevent hypoglycemia. the glucose is quickly metabolized in the body leaving free water. Although considered a hydrating solution would not be the best FIRST choice in this situation because the client is hypotensive.9% sodium chloride.Incorrect: A hypotonic solution such as . A hypertonic solution would draw water out of the cells causing further dehydration and could cause severe cerebral damage. Once the client's blood pressure is improved. other hydrating solutions such as Dextrose 5% in . However.45% sodium chloride is useful for daily maintenance of body fluid but not for replacement therapy. which intravenous solutions would be the best choice? Incorrect: Dextrose 5% in water is considered an isotonic solution in the container.e. reduce the potassium content if signs of hyperkalemia are present). is contraindicated in this situation. Because it is hypotonic it is not the best choice for initial IV therapy in the client who is hypotensive. Hypertonic saline is used when treating a client with severe hyponatremia. pulse 110/minute.achieving orgasm will be impossible.Incorrect: As described above.9% sodium chloride 3% sodium chloride 89 While setting up total parenteral nutrition (TPN) for a client. The best solution to expand the vascular space is an isotonic solution such as 0. In the initial stages of fluid replacement. which can occur rapidly if the infusion rate were to be increased or decreased.Correct: A . a uniform infusion rate should be maintained to prevent changes in blood glucose. the first objective is to raise the ECF volume. It should also be noted that the free water in D5W could dilute the serum sodium level. the nurse performs which intervention to prevent fluid and electrolyte imbalance? Incorrect: When infusing TPN the nurse should maintain a uniform infusion rate to prevent hypo or hyperglycemia or other fluid/electrolyte imbalances. Dextrose 5% in water .
However. the client's anxiety and attempts to cough in addition to the high-pressure alarm strongly suggest secretions in the airway. it may be appropriate to evaluate the position of an endotracheal tube. sneezing. close monitoring and follow-up care. the nurse evaluates the client's understanding of the use of eyedrops. Suctioning should occur first. The first action the nurse should take is: Incorrect: Although clients who are excessively anxious and fight the ventilator may be sedated or given a paralyzing agent. behavior suggests the need for airway clearance. However. . There is no cure for glaucoma but it can be controlled. it is equally important to continue to check the flow rate hourly and not assume that the pump is functioning properly. In addition." "My wife makes sure I do not drive after dark. but further loss can be prevented. 90 During a home visit to an elderly client with glaucoma. Vision that has been lost to elevated intraocular pressure cannot be restored.Incorrect: The client understands the importance of avoiding increased pressure in the eye. In this case. and straining to have a bowel movement. Which statement. if made by the client.Correct: This statement by the client indicates more teaching is required. life-long treatment.Incorrect: The client's wife understands the importance of safety. It would also be important to check the tubing for kinks or excessive water that could also sound the high-pressure alarm." 91 A client with a tracheostomy tube on mechanical ventilation suddenly becomes restless and anxious and attempts to cough. Discontinue the infusion if signs of electrolyte imbalances occur. Reduce the flow rate if signs of overhydration develop. Set up an infusion pump and check the flow rate hourly. Adjust the flow rate based on finger stick glucose levels.safeguard against too rapid infusion of any IV solution is to use an infusion pump. would indicate additional teaching is required? Incorrect: The client has described the proper technique for instilling ophthalmic drops or ointments. Clients with glaucoma should avoid activities that increase intraocular such as bending from the waist. The high-pressure alarm sounds on the ventilator. "I should pull my lower eyelid down and place the drop/s onto the lower lid. sources of the client's anxiety should be determined and addressed. vomiting.Incorrect: An x-ray is not indicated in this situation." "I have been careful to avoid becoming constipated. Blindness can be prevented by early detection. if displaced it could also cause the high-pressure alarm to sound.Incorrect: It is important to empty water from the ventilator tubing to prevent bacterial growth and pneumonia.Correct: The highpressure alarm sounds when peak inspiratory pressure reaches the set alarm limit. The use of miotic drugs causes pupil constriction and may adversely affect the client's night vision and adaptation to dark environments." "I'm glad I can stop taking this medicine when my vision improves.
obtain a chest x-ray. they cause cardiac stimulation and increase the heart rate. empty water from the ventilator tubing. digitalis is a negative chronotropic drug (slows the cardiac rate). It is also important in the treatment of pulmonary edema because it eases dyspnea and reduces preload (vasodilator effect).Correct: Digitalis preparations such as digoxin (Lanoxin) are classified as positive inotropic agents that work by increasing the force and strength of myocardial contraction. Beta-adrenergic agonists Narcotic analgesic Diuretics Digitalis preparations 94 A 68-year-old male client has a permanent tracheostomy tube following total laryngectomy.Incorrect: Because of the local anesthetic sprayed on the tongue and oropharynx. the first nursing activity is to suction the tracheostomy tube. suction the tracheostomy tube. frank bleeding should be immediately reported. These symptoms may indicate trauma to the larynx or vocal cords. Blood-streaked sputum Difficulty swallowing Progressive dyspnea Throat discomfort 93 Which classification of medication is primary in the treatment of congestive heart failure because of its ability to increase the force and strength of the cardiac contraction and slow the heart rate? Incorrect: Although beta-adrenergic agonists such as isoproterenol (Isuprel) enhance myocardial contraction. laryngeal edema or laryngospasm (stridor) and increasing shortness of breath. 92 A 48-year-old male had a bronchoscopy with tissue biopsy 30 minutes ago.Correct: Following a bronchoscopy it is essential that the nurse monitor for frank bleeding.Incorrect: A moderate amount of throat discomfort is expected following a bronchoscopy and should be managed with warm saline gargles once the client is able to effectively swallow. and attempting to cough.indicating secretions in the airway or a mucous plug. However. difficulty swallowing is expected until cough and gag reflexes return.Incorrect: Diuretics are also primary drugs in the treatment of congestive heart failure but are given to increase excretion of sodium and water from the body. The client calls the nurse and reports the following symptoms. administer an antianxiety agent. In addition. The most appropriate goal for the first postoperative day would be for the client to: . Which one should prompt the nurse to immediately notify the practitioner? Incorrect: Blood-streaked sputum may occur following a tissue biopsy.Incorrect: Morphine sulfate is a narcotic analgesic used to decrease pain. Since the client is restless. anxious.
diabetes insipidus. Although serious and potentially fatal. Examples of intrarenal causes include glomerulonephritis. the most common complication after an MI is dysrhythmias. antiinflammatory agents. A patent airway is a priority outcome immediately postop and it is reasonable to expect the client will assist in coughing and mobilizing secretions through the tracheostomy tube or laryngeal stoma. help maintain a patent airway.Incorrect: Free wall rupture of a weakened area of the myocardium can occur but is very rare. malignant hypertension. excessive use of diuretics.Incorrect: Intrarenal failure is caused by damage to the kidney tissues and structures and includes tubular necrosis. has a coagulation disorder. frequently develops kidney stones. hemorrhages during surgery. they are rare. neoplasms. consume oral fluids without aspirating. verbalize fear and anxiety. Communication can however be facilitated using other techniques.Incorrect: Although early ambulation is advocated in most all post-operative clients to prevent atelectasis and paralytic ileus.Incorrect: Nephrotoxic drugs such as the aminoglycosides are classified as intrarenal causes of acute renal failure. burns.Incorrect: Although ventricular aneurysms can develop following myocardial infarctions involving the entire myocardium. will be unable to verbalize because the larynx (vocal cords) have been removed.Incorrect: A nasogastric tube is used for food and fluids to minimize contamination of the pharyngeal and esophageal suture lines and to prevent fluid from leaking through the wound into the trachea before healing occurs. ambulate independently. nephrotoxic drugs such as gentamicin (an aminoglycoside). cirrhosis.Correct: Prerenal causes of ARF occur secondary to intravascular volume depletion. dehydration. Conditions that lead to decreased cardiac output such as congestive heart failure and dysrhythmias are other prerenal causes of ARF. who is at increased risk for developing acute renal failure (ARF) from a prerenal cause? The person who: Incorrect: Postrenal failure is caused by obstruction of urine flow between the kidney and urethral meatus as in such conditions as renal calculi. and alteration in renal blood flow.Correct: Some degree of airway obstruction is common in clients following laryngectomy related to edema from surgery or radiation prior to the surgery. nephrotoxicity. although very anxious following surgery. In . and prostatic hypertrophy. tetracyclines. it would be unrealistic and perhaps dangerous to expect the laryngectomy client to ambulate independently the first postoperative day.Correct: Dysrhythmias often occur secondary to the ischemic processes of coronary artery disease and myocardial infarction. Examples of conditions leading to hypovolemia include hemorrhage. 95 Of the following individuals. is receiving an aminoglycoside.Incorrect: The laryngectomy patient. coagulopathies. and sulfonamides. The most common complication after a myocardial infarction (MI) is: Incorrect: Cardiogenic shock is caused by severe myocardial dysfunction and occurs in 5% to 10% of clients with acute myocardial infarction.
carbohydrates should be restricted. In planning nutritional management the nurse knows that: Incorrect: This client's height and weight indicate that she is overweight. Carbohydrates must be distributed on a consistent basis so that blood nutrients match insulin levels. The most appropriate nursing measure is to elevate the head of the . direct damage to the myocardial cell can cause electrolyte imbalances that alter the action potential. diet alone is probably sufficient for glucose control. The current nutritional management for diabetes is to maintain reasonable weight and control blood glucose without compromising health. ventricular aneurysms. A large percentage (80-90%) of persons diagnosed with type 2 diabetes are overweight. The nurse notes the client is 5 feet. CHO. weight reduction is an important goal for care.Incorrect: Although obesity is a significant risk factor for type 2 diabetes. and venous return to the right heart increases with elevation of the legs.Incorrect: A common misconception in diabetes management is that carbohydrates (CHO) be restricted.Incorrect: Increasing oxygen delivery will not eliminate the problem of orthopnea or nocturnal dyspnea that occurs when the legs are elevated to the level of the heart and venous return is increased causing increased fluid in the lungs. 4 inches and weighs 160 pounds. and proteins but to reduce total calories. The client awakes suddenly with severe shortness of breath that subsides only after sitting upright for 10-30 minutes. The client's nutritional history indicates a diet high in carbohydrates and moderately sedentary lifestyle. Attaining and maintaining ideal body weight are major criteria in diabetes management. Distribution of CHOs helps prevent increases in blood glucose following meals. 98 An elderly client with a diagnosis of congestive heart failure complains of paroxysmal nocturnal dyspnea. and allows the blood glucose to return to pre-meal levels before the next meal. Clients who need to reduce weight are taught to maintain balanced intake of fat.Correct: Weight is a major factor in monitoring diabetes control. Clients experiencing orthopnea must sleep using several pillows or in a semi-Fowler's position.addition to blocks along the conduction pathway. A caloric increase would be inappropriate especially since this client's activity level is light. Which nursing actions is most appropriate for the nurse to institute? Correct: Paroxysmal nocturnal dyspnea occurs 2-5 hours after the client lies down because chest expansion diminishes in the recumbent position resulting in decreased ventilation. dietary management and weight loss is usually not sufficient to control blood glucose levels in the client diagnosed with type 2 diabetes. creating a variety of dysrhythmias. 97 The nurse is caring for a client with Type 2 diabetes mellitus. dysrhythmias. Many clients with type 2 diabetes require oral hypoglycemics to help decrease insulin resistance or augment insulin secretion. an increase in caloric intake is recommended. rupture of the ventricular wall. shock.
In contrast. Increase O2 to 6 L per nasal cannula. exaggerated muscle weakness. To determine whether these symptoms are the result of cholinergic versus myasthenic crisis.Correct: As explained above. Therefore. If the client is currently receiving diuretics. Instead. Purulent drainage is a sign of wound infection. 99 A client diagnosed with myasthenia gravis is brought to the emergency department with severe dyspnea. and dysphagia.Incorrect: Restricting fluids may or may not be indicated. slight edema. Of the following drug responses.Incorrect: Fever. bedrest without elevation of the head of the bed will not diminish the problem of orthopnea or nocturnal dyspnea.Incorrect: Adhesions may form after wound healing has occurred.Incorrect: In cholinergic crisis. cholinergic crisis is an exacerbation of muscle weakness caused by overmedication. Elevate the head of the bed.bed. improved breathing would be expected if the client were in myasthenic crisis. Tensilon (a short-acting anticholinsterase) produces a temporary improvement in myasthenic crisis but no improvement or worsening of symptoms in cholinergic crisis. and tachycardia indicate infection. clients who are experiencing myasthenic crisis respond positively to the Tensilon test with a temporary improvement in muscle tone. the nurse determines that a 2-day-old surgical incision is likely to be inflamed based on which physical assessment data? Correct: Tissue redness (erythema). Institute strict bedrest. Erythema. Fever.Incorrect: Improvement in the ability to swallow following Tensilon administration would be expected if the client were in myasthenic crisis. a fluid restriction may be contraindicated to avoid fluid volume deficit. and increase warmth . the physician administers the Tensilon test. Myasthenic crisis represents an exacerbation of the symptoms caused by undermedication with anticholinesterase drugs.Incorrect: Although bedrest decreases the workload of the failing heart. weakness increases and muscle twitching may be observed around the eyes and face. tachycardia (increased heart rate) and tachypnea (increased respiratory rate) are signs of infection. muscle tone does not improve after administration of Tensilon.Incorrect: Pain and drainage may be normal at an incisional site and are not a sign of inflammation. Breathing remains unchanged Facial twitching occurs Muscle strength briefly improves Dysphagia worsens 100 When differentiating between wound inflammation and wound infection. Restrict fluids for the next 24 hours. slight swelling (edema) and increased warmth are signs of wound inflammation. which would indicate to the nurse that myasthenic crisis is present? Incorrect: Myasthenia gravis involves a decrease in the number and effectiveness of acetylcholine receptors at the neuromuscular junction resulting in progressive muscle weakness. purulent drainage. The increase of fluid returning to the lungs when lying in a supine position with the legs elevated can best be averted by elevating the head of the bed.
Pain at the surgical site and drainage Adhesions and purulent drainage Fever. tachycardia. and tachypnea .
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