A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?
A. Keep the client's personal care items in the bathroom.
B. Keep the overhead lights on in the client's bedroom while the client is sleeping.
C. Remind the client to scan their complete range of vision during ambulation.
D. Secure the client's extension cords under carpeting. | Answer: C. Remind the client to scan their complete range of vision during ambulation.
- The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.
Rationale:
A - The nurse should instruct the client's family to keep the client's personal care items within the client's reach to reduce the risk for falls.
B - The nurse should instruct the family to use nightlights in the client's bedroom and bathroom to reduce the risk for falls. Keeping the overhead lights on while the client is sleeping can disrupt the client's circadian rhythm.
D - The nurse should instruct the client's family that they should secure extension cords to the client's baseboards using electrical tape, rather than placing them under carpeting. This practice can help to reduce the risk for falls. |
A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
A. Obtain a sputum specimen to determine if there is colonization.
B. Bathe the client using chlorhexidine solution.
C. Place the client in droplet isolation.
D. Restrict visits from the client's friends and family. | Answer: B. Bathe the client using chlorhexidine solution.
- The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.
Rationale:
A - The nurse should obtain a nasal specimen to determine if there is colonization of MRSA.
C - The nurse should place the client in contact isolation to decrease the risk of the spread of MRSA.
D - The nurse does not need to restrict the client's visitors. The nurse should instruct the client's friends and family to wear gowns and gloves when visiting the client to decrease the risk of the spread of MRSA. |
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?
A. Ginkgo biloba
B. Glucosamine
C. Calcium
D. Vitamin C | Answer: C. Calcium
- Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.
Rationale:
A - Ginkgo biloba reduces the pain associated with peripheral vascular disease by promoting vasodilation. It can interact with medications that have anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine.
B - Glucosamine treats osteoarthritis by decreasing inflammation and stimulating the body's production of synovial fluid and cartilage. It can interact with medications that have antiplatelet or anticoagulant properties, but it is not known to interfere with the absorption of levothyroxine.
D - Vitamin C promotes wound healing. It can cause a false negative in fecal occult blood tests, but it is not known to interfere with the absorption of levothyroxine. |
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should take calcium supplements so the medication will work better in my system."
B. "I am taking this medication to increase my energy level."
C. "This medication can cause my blood pressure to drop."
D. "I will not need to restrict protein in my diet while taking this medication." | Answer: B. "I am taking this medication to increase my energy level."
- The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.
Rationale:
A - A client who has chronic kidney disease should have adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal.
C - Therapy with erythropoietin increases RBC production, which can result in hypertension, not hypotension.
D - Erythropoietin does not affect the client's protein requirements, but the client should continue to restrict protein as prescribed by the provider to manage kidney disease. |
BUN 24 mg/dL (10 to 20 mg/dL)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
HCO3- 24 mEq/L (22 to 26 mEq/L)
Oxygen saturation 88% on room air
PCO2 50 mm Hg (35 to 45 mm Hg)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse?
Select all that apply. (Select All that Apply.)
A. BUN level
B. Chest x-ray
C. Calcium level
D. HCO3- level
E. Oxygen saturation level
F. PCO2 level
G. WBC count | Answer: A, B, E F, G
PCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse.
BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse. |
The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.
Nurses' Notes:
A. Client is short of breath and has a productive cough with yellow mucus.
B. "I could barely breathe when I got up this morning and I had a throbbing headache."
C. Capillary refill less than 2 seconds.
D. Client is diaphoretic.
E. Crackles heard in posterior lungs.
F. Pedal pulses +2 bilaterally. | Answer:
- Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem.
- "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem.
- Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a potential problem.
- Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the expected reference range and indicates adequate perfusion.
- Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem.
- Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected reference range and indicates adequate perfusion. |
Oxygen saturation 88% on room air
Client reports decreased appetite for the past 2 days.
BUN 24 mg/dL (10 to 20 mg/dL)
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache."
The nurse should first address the client's (Oxygen Saturation/Loss of Appetite/BUN level) followed by the client's (Heart Rate/Temperature/Headache) | Answer: The nurse should first address the client's OXYGEN SATURATION followed by the client's TEMPERATURE
- The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. - The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate.
Rationale: - Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. - BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. - Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. - Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first. |
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling sick for the last few days and states, "I could barely breathe when I got up this morning and I had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs. Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.
Temperature 38.6° C (101.5° F)
Oxygen saturation 88% on room air
Anticipated or Nonessential or Contraindicated
A. Administer oxygen at 3 L/min via nasal cannula.
B. Famotidine 40 mg PO daily
C. Limit the client's fluid intake to 1,500 mL per day.
D. Obtain a sputum culture and sensitivity.
E. Cough and deep breathe every 2 hr.
F. Acetaminophen 500 mg PO every 6 hr as needed.
G. Perform neurological checks every 2 hr. | Anticipated:
A - The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. D - The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed.
E - The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. F - The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Nonessential: B - Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily. G - The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Contraindicated: C - The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated. |
The nurse is reviewing the client's medical record.
Select the 3 findings that require nursing intervention.
A. WBC count
- 15,000/mm3 (5,000 to 10,000/mm3)
B. Temperature
- 38.6° C (101.5° F)
C. Potassium level
- 5.4 mEq/L (3.5 to 5 mEq/L)
D. Heart rate
- 88/min
E. Oxygen saturation
- 97% on 2 L/min of oxygen via nasal cannula | Answer: A, B, C
A - The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. B - The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing intervention. C - The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention.
Rationale: D - The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. E - The nurse should identify the client's oxygen saturation has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention. |
The nurse is reviewing the client's medical record from Day 5.
Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again.
Nurse's Notes
Day 5 0800:
A. Heart rate 72/min
B. Respiratory rate 20/min
C. Blood pressure 128/56 mm Hg
D. Oxygen saturation 95% on room air
E. Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation.
F. Cough is productive with yellow mucus. | Answer: A, B, C, D
- The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. - The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving. Rationale: E - The nurse should identify that the client's lungs sounds are still diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. F - The client's cough is still productive with yellow mucus due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. |
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
A. "I should avoid walking as much as possible."
B. "I should sit down and read for several hours a day."
C. "I will wear clean graduated compression stockings every day."
D. "I will keep my legs level with my body when I sleep at night." | Answer: C. "I will wear clean graduated compression stockings every day."
- The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.
Rationale:
A - A client who has venous insufficiency should maintain an exercise regimen, such as routine walking, to decrease venous stasis.
B - A client who has venous insufficiency should avoid sitting or standing for prolonged periods of time due to the risk of developing deep-vein thrombosis or skin breakdown.
D - A client who has venous insufficiency should elevate the legs above heart level while in bed to facilitate venous return and avoid venous stasis. |
A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?
A. Metoprolol
B. Bupropion
C. Atorvastatin
D. Naproxen | Answer: D. Naproxen
- Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.
Rationale:
A - Metoprolol does not interact with feverfew.
B - Bupropion does not interact with feverfew.
C - The nurse should recognize that the effect of atorvastatin is decreased by St. John's wort. |
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?
A. Elevated blood pressure
B. Dehydration
C. Stress ulcers
D. Hypernatremia | Answer: C. Stress Ulcers
- Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.
Rationale:
A - Positive pressure from mechanical ventilation inhibits blood return to the heart, leading to decreased cardiac output and hypotension.
B - Decreased cardiac output associated with mechanical ventilation places the client at risk for fluid retention.
D - Hyponatremia can occur secondary to fluid retention that results from long-term mechanical ventilation. |
A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?
A. Avoid foods that are high in ascorbic acid.
B. Add oatmeal to the water when taking a tub bath.
C. Urinate every 6 hr.
D. Take daily cranberry supplements. | Answer: D. Take daily cranberry supplements.
- The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.
Rationale:
A - A client who is at risk for developing UTIs should increase intake of ascorbic acid to acidify the urine.
B - A client who is at risk for developing UTIs should take showers rather than tub baths because bacteria in the bath water can enter the urethra.
C - A client who is at risk for developing UTIs should urinate every 2 to 4 hr. |
A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?
A. Hyperreflexia
B. Increased blood pressure
C. Respiratory paralysis
D. Tachycardia | Answer: C. Respiratory paralysis
- The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.
Rationale:
A - Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of magnesium sulfate.
B - Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can result in systemic vasodilation and subsequent hypotension.
D - Magnesium sulfate is used to treat cardiac dysrhythmias, such as torsades de pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an adverse effect of magnesium sulfate. |
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)? mL/hr | 167 mL/hr Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 4,000 mL Step 3: What is the total infusion time? 24 hr Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for X.
Volume (mL)X mL/hr = Time (hr)
4,000 mLX mL/hr = 24 hr
X mL/hr = 166.67
Step 6: Round if necessary. 166.67 = 167 mL/hr. Step 7: Determine if the amount to administer makes sense. If the prescription reads 2,000 kcal to infuse over 24 hr, it makes sense to administer 167 mL/hr. The nurse should set the IV pump to deliver TPN IV at 167 mL/hr. Follow these steps to calculate the infusion rate using the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.)
X mL/hr =
Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 4,000 mLX mL/hr = 24 hr Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 4,000 mLX mL/hr = 24 hr
Step 4: Solve for X. X mL/hr = 166.67. Step 5: Round if necessary. 166.67 = 167 mL/hr. Step 6: Determine if the amount to administer makes sense. If the prescription reads 2,000 kcal to infuse over 24 hr, it makes sense to administer 167 mL/hr. The nurse should set the IV pump to deliver TPN IV at 167 mL/hr. |
A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching?
A. Position tabletop clocks with multi-colored backgrounds throughout the home.
B. Explain how to complete a task while having the client do the task.
C. Place a calendar on the wall with days and weeks included.
D. Create complete outfits and allow the client to select one each day. | Answer: D. Create complete outfits and allow the client to select one each day.
- The family should place completed outfits on hangers and allow the client to select which one to wear each day.
Rationale:
A - The family should use easy-to-read clocks with a plain background to minimize confusion and allow the client to find and read them easily.
B - The family should explain how to complete a task before there is a need to complete the task to minimize confusion and frustration.
C - The family should place a calendar on the wall with the present day available to view to minimize confusion and assist in orientation. |
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?
A. Explain procedures as they occur to the client.
B. Place personal items, such as pictures, at the client's bedside.
C. Orient the client to their location once a shift.
D. Encourage the family members to remain home until the client has adjusted. | Answer: B. Place personal items, such as pictures, at the client's bedside.
- The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.
Rationale:
A - The nurse should plan to explain all procedures and routines to the client before they occur to decrease confusion and anxiety.
C - The nurse should plan to orient the client to person, place, and time frequently during a shift to decrease confusion and anxiety.
D - The nurse should plan for family members and friends to visit often to decrease confusion and anxiety and to reinforce cognitive support. |
A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet?
A. 12 almonds
B. One small banana
C. 1 tbsp peanut butter
D. 1/2 cup tomato juice | Answer: A. 12 almonds
- The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.
Rationale:
B - The nurse should recommend a different food because there is another choice that contains more calcium. One small banana contains 5 mg of calcium.
C - The nurse should recommend a different food because there is another choice that contains more calcium. One tbsp of peanut butter contains 8 mg of calcium.
D - The nurse should recommend a different food because there is another choice that contains more calcium. A half cup of tomato juice contains 12 mg of calcium. |
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?
A. History of Asthma
B. Appendectomy 1 year ago
C. Penicillin allergy
D. Total knee arthroplasty 6 months ago | Answer: A. History of Asthma
- A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.
Rationale:
B - A history of an appendectomy does not have an effect on a CT scan. However, clients who have a history of diabetes mellitus, renal impairment, or heart failure have an increased risk for renal failure when contrast media is used and require further screening.
C - A penicillin allergy does not have an effect on a CT scan. However, a client who is taking certain medications, such as aminoglycosides, NSAIDs, and the biguanide metformin, is at increased risk for renal damage and requires further screening.
D - A total knee arthroplasty does not have an effect on a CT scan. |