A client is admitted to the hospital with a myasthenic crisis. The nurse should anticipate which potential precipitating factors for this event?
Rationale:
A client in a myasthenic crisis is most likely precipitated by taking too little of the prescribed medication. Insufficient medication leads to inadequate acetylcholine at the neuromuscular junction, worsening muscle weakness and respiratory compromise. Maintaining proper medication dosage is critical to control symptoms and prevent crisis, as underdosing directly diminishes neuromuscular transmission efficiency.
A: The client consumes a high purine diet This choice relates to gout, not myasthenic crisis, making it unrelated to neuromuscular transmission or muscle weakness precipitating factors.
B: Taking too much of their medication Excess medication typically causes cholinergic crisis, not myasthenic crisis, involving overstimulation rather than underactivity, thus differing fundamentally in pathophysiology.
D: Taking their medication while on an empty stomach Food intake timing rarely causes myasthenic crisis; absorption issues generally don't precipitate acute neuromuscular weakness in this context.
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
Rationale:
Visitors should be limited to 2 hours per day to reduce radiation exposure while allowing social interaction. This balance ensures safety and supports the client's emotional well-being during brachytherapy treatment, which involves internal radiation where exposure time directly influences radiation dose received by others in proximity to the client.
A: Discard the radioactive device in the client's trash can poses a serious safety hazard, as radioactive materials require special handling and disposal protocols to prevent environmental contamination and protect healthcare workers.
B: Keep soiled bed linens in the client's room increases contamination risk. Proper protocol requires placing linens in designated containers for radiation safety and infection control, preventing radiation spread outside the isolated environment.
C: Instruct visitors to remain 3 feet from the client underestimates safety measures. The recommended distance is at least 6 feet to minimize radiation exposure effectively, so 3 feet does not sufficiently protect visitors.
A patient is admitted to the respiratory unit with flail chest. Which answer best describes this diagnosis?
Rationale:
Flail chest is a condition characterized by multiple fractures of the ribs resulting in a segment of the chest wall becoming detached. This occurs when several adjacent ribs break in multiple places, causing a free-floating segment that moves paradoxically during respiration, impairing effective breathing and requiring careful respiratory management.
A: A condition in which there is a puncture or rupture of the lung describes a lung injury, not the detachment of a rib segment caused by multiple fractures.
B: Presence of air or gas in the pleural cavity defines pneumothorax, not the instability of a chest wall segment caused by fractured ribs.
D: Collapse of the lung, or atelectasis, involves alveolar deflation rather than the structural detachment of ribs seen in flail chest.
A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Rationale:
Elective cardioversion is the appropriate action for a client with ventricular tachycardia who is stable, as it delivers synchronized shocks to restore normal rhythm without causing additional arrhythmias. This controlled approach is preferred when the client maintains a pulse and consciousness, differentiating it from emergency interventions used in pulseless or unstable VT situations.
B: Defibrillation delivers unsynchronized shocks intended for pulseless ventricular fibrillation or pulseless VT, not for stable VT with a pulse, making it unsuitable for this client’s condition.
C: CPR is reserved for clients without a heartbeat or respirations, so it is unnecessary when the client is stable and experiencing ventricular tachycardia with a pulse.
D: Radiofrequency catheter ablation is a long-term treatment option for recurrent VT, not an immediate intervention for acute episodes confirmed by ECG.
When caring for a patient after lumbar spinal surgery, the nurse would immediately report which finding to the healthcare provider?
Rationale:
Loss of sensation to the perineum, buttocks, inner thighs, and back of the legs must be immediately reported to the healthcare provider. This finding suggests possible cauda equina syndrome, a serious neurological emergency requiring urgent intervention to prevent permanent damage and preserve motor, sensory, and bladder function after lumbar spinal surgery.
B: The patient’s nausea and inability to void within 4 hours indicate discomfort but do not signify an immediate neurological emergency requiring urgent reporting. Monitoring and supportive care are appropriate initially.
C: Mild low back pain is expected after lumbar spinal surgery and typically does not necessitate immediate notification unless it worsens or is accompanied by neurological symptoms.
D: A single episode of emesis is common postoperatively due to anesthesia effects or medications and does not require urgent communication unless persistent or accompanied by other concerning signs.
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?
Rationale:
Painless red vaginal bleeding supports the diagnosis of placenta previa. Placenta previa involves the placenta covering the cervix, causing painless bleeding as the cervix dilates. This bleeding is typically bright red without associated pain or contractions, distinguishing it from other causes of bleeding in pregnancy that involve uterine pain or contractions.
A: Intermittent abdominal pain following passage of bloody mucus describes symptoms more typical of labor or infection, not placenta previa, which usually presents with painless bleeding.
B: Increasing abdominal pain with a non-relaxed uterus indicates contractions or abruption, conditions distinct from placenta previa’s painless bleeding presentation.
D: Abdominal pain with scant red vaginal bleeding suggests placental abruption, where pain is prominent, unlike the painless bleeding of placenta previa.
A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)
Rationale:
Increased urine specific gravity, changes in the client's behavior, complaints of nausea, and severe headache should be reported to the provider. These findings indicate worsening hyponatremia and fluid imbalance related to SIADH, posing risks for neurological complications. Early intervention can prevent seizures, cerebral edema, and further deterioration of the client's condition. Prompt reporting ensures timely management.
E: Client's urine output is only 50 cc/hr This low urine output may reflect concentrated urine typical in SIADH but alone does not signify immediate danger or require urgent reporting compared to neurological symptoms or lab abnormalities. It is expected due to water retention.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
Rationale:
Maintaining the client on NPO status is essential in acute pancreatitis care to rest the pancreas and reduce stimulation of pancreatic secretions. This intervention helps prevent further inflammation and allows the pancreas to heal by minimizing digestive enzyme release that could exacerbate tissue damage and pain. Nutritional support is typically provided intravenously until symptoms improve.
A: Administer antihypertensive medications does not address the primary treatment goals of acute pancreatitis, which focus on pancreatic rest and symptom management rather than blood pressure control.
C: Place the client in a supine position may increase abdominal discomfort and does not aid in reducing pancreatic inflammation or pain relief.
D: Monitor the client for hypercalcemia is unnecessary as acute pancreatitis is more commonly associated with hypocalcemia, not elevated calcium levels.
A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9. Which of the following statements from the nurse is appropriate?
Rationale:
Your average blood sugar is high. Hemoglobin A1C reflects the average blood glucose levels over the past two to three months. A value of 9 indicates poor long-term glucose control, suggesting sustained hyperglycemia rather than isolated spikes or lows. This measure helps evaluate overall diabetes management, making the nurse's statement accurate and appropriate for communicating the client’s glycemic status clearly and effectively.
A: You have many dangerously low blood sugar levels. This statement incorrectly suggests hypoglycemia, which an elevated A1C does not indicate; it reflects sustained high blood sugar, not frequent low episodes.
C: Your blood sugar is too high after meals. Postprandial glucose levels are not directly reflected by A1C, which averages all blood sugar readings, so this option inaccurately localizes the problem.
D: Your blood sugar is very unstable. An elevated A1C indicates chronic hyperglycemia, not necessarily variability or instability; this choice misrepresents the nature of the A1C result.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
Rationale:
Dysmenorrhea that is unresponsive to NSAIDs is consistent with a diagnosis of endometriosis. Endometriosis commonly causes severe menstrual pain that does not improve with standard treatments like NSAIDs. This symptom reflects the chronic inflammatory process and ectopic endometrial tissue causing persistent, debilitating pain during menstruation, distinguishing it from other gynecological conditions.
B: Heavy menstrual bleeding often relates to other disorders like fibroids or hormonal imbalances, not typically characteristic of endometriosis, which primarily causes pain rather than increased bleeding volume.
C: A positive family history of fibroids indicates a genetic predisposition to benign uterine tumors, differing pathophysiologically from endometriosis, which involves ectopic endometrial tissue growth.
D: Pelvic pain after intercourse can occur with endometriosis but is less specific than dysmenorrhea unresponsive to NSAIDs and may be caused by other pelvic or vaginal conditions.
A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician's order should the nurse implement?
Rationale:
Administer morphine 2-4 mg IV prn for pain.
This order is essential for managing acute postoperative pain following a below-the-knee amputation, especially in a diabetic patient who may have heightened pain sensitivity. Effective pain control promotes comfort, facilitates mobility, and prevents complications like increased blood pressure or delayed healing, ensuring a smoother recovery in the immediate post-anesthesia phase.
B: Apply a figure of 8 pressure dressing starting day two post-operatively. This is premature as pressure dressings typically start immediately post-op to control bleeding and swelling, not delayed until day two.
C: Administer antibiotics as prescribed. Antibiotic administration is important but is a general measure; pain control is the priority for immediate postoperative care in this context.
D: Apply ice to the stump for 60-90 minutes. Prolonged ice application risks tissue damage and is not a standard postoperative intervention for amputation pain control or swelling management.
A client reports visual disturbances followed by debilitatingPain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching? Select all that apply
Rationale:
Identity and avoid triggers, get adequate sleep, identify ways to reduce stress, and NSAIDs are ineffective. These strategies address common migraine management approaches, emphasizing prevention through lifestyle adjustments and acknowledging that NSAIDs may not always relieve severe migraine symptoms, guiding appropriate treatment choices and patient education for symptom control and quality of life improvement.
C: Anticipate staying in bed up to 10 days contradicts typical migraine duration, which usually lasts hours to a few days, making prolonged bed rest unnecessary and unrealistic for most patients.
In providing care to a patient admitted with an acute asthma exacerbation, the nurse prepares which 'rescue' medication for administration first?
Rationale:
Short-acting beta2-adrenergic agonists are the first 'rescue' medication administered to patients experiencing an acute asthma exacerbation. These drugs rapidly relax bronchial smooth muscle, providing quick relief from airway constriction and improving airflow, which is critical during an asthma attack. Their fast onset of action makes them essential for immediate symptom management in acute respiratory distress situations.
A: Long-acting beta2-adrenergic agonists primarily maintain long-term asthma control and do not act quickly enough to relieve acute bronchospasm, making them unsuitable as initial rescue therapy during an exacerbation.
C: Mucolytics help thin mucus to clear airways but do not provide immediate bronchodilation, so they are not appropriate for rapid symptom relief in acute asthma episodes.
D: Inhaled anti-inflammatories reduce airway inflammation over time but have a delayed onset and are not effective for immediate symptom reversal during acute asthma attacks.
A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?
Rationale:
Unilateral upper and lower facial weaknesses including the forehead best characterize Bell's Palsy due to facial nerve (cranial nerve VII) paralysis affecting all facial muscles on one side.
C involves complete facial muscle paralysis, typical in Bell's Palsy, differentiating it from central causes sparing the forehead due to bilateral cortical innervation.
A: Painful areas along nerve branches suggest trigeminal nerve involvement, not the motor facial nerve paralysis seen in Bell's Palsy.
B: Decreased visual acuity relates to optic nerve dysfunction, unrelated to Bell's Palsy, which primarily affects facial muscle movement.
D: Facial dropping with limb weakness indicates a stroke affecting multiple brain areas, unlike Bell's Palsy, which is isolated to the facial nerve.
A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first?
Rationale:
The nurse should first don sterile gloves. Proper hand hygiene and wearing sterile gloves prevent contamination of the wound and specimen, ensuring accurate culture results. This step maintains aseptic technique, protecting both the patient and nurse from infection and cross-contamination before any wound manipulation or sample collection occurs, which is critical for obtaining a reliable aerobic wound culture.
A: Swabbing the wound bed prematurely risks contaminating the sample and violating aseptic technique, as the area may still have debris or microorganisms that should be removed before collection.
B: Cleansing the wound surroundings is necessary but follows donning sterile gloves to maintain sterility; performing this step first could introduce contaminants.
D: Placing the collection tube in a specimen bag occurs after sample collection, not before, so it does not initiate the proper procedure for obtaining a culture.
The nurse is providing care to a patient in the post anesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding correlates to this postoperative complication?
Rationale:
Tachycardia is the assessment finding that correlates with significant blood loss in the postoperative patient. Blood loss reduces circulating volume, causing the heart to beat faster to maintain adequate tissue perfusion and oxygen delivery. This compensatory mechanism helps stabilize blood pressure and vital organ function during hypovolemia following surgery, making tachycardia a critical indicator in the PACU setting.
A: Hypertension Elevated blood pressure is not typical after substantial blood loss because hypovolemia usually leads to decreased blood pressure due to reduced circulating volume, making hypertension an unlikely sign of this postoperative complication.
B: Hypothermia Although hypothermia can occur postoperatively, it does not specifically indicate blood loss. Blood loss primarily affects circulatory status, whereas hypothermia relates more to environmental exposure or impaired temperature regulation.
D: Bradypnea Slow respiratory rate does not directly correlate with blood loss. Typically, blood loss triggers compensatory mechanisms like increased heart rate, but respiratory rate changes are less specific and not a primary indicator in this context.
A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?
Rationale:
A: I need to walk slowly as I lose my balance often. This statement indicates a fall risk that requires immediate attention, especially in peripheral artery disease (PAD) patients who may have compromised circulation and nerve function. Reporting balance issues allows timely intervention to prevent injury, as falls can lead to serious complications in clients with PAD, including delayed wound healing and increased morbidity.
B: I have a small-healed area on my spine that is painful. This reflects a past injury rather than an acute safety concern needing immediate provider notification. Painful but healed wounds are less urgent unless signs of infection or deterioration appear.
C: I don't go out much because of the pain in my legs. Avoidance due to leg pain is expected in PAD but does not represent an urgent safety issue requiring provider notification compared to balance impairment.
D: It makes me sad that I can't keep up with my grandchildren. Feelings of sadness indicate emotional distress but do not directly threaten physical safety or require immediate reporting in the context of PAD assessment.
Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?
Rationale:
Maintaining strict aseptic technique with all procedural dressing changes is the priority intervention for a patient with a ventriculostomy to prevent infection and complications.
C: Strict aseptic technique minimizes the risk of introducing pathogens during dressing changes, which can lead to ventriculitis or meningitis, potentially worsening intracranial pressure and patient outcomes. This protocol safeguards patient safety and ensures accurate ICP monitoring.
A: Beware of changes in ICP related to leaking cerebrospinal fluid (CSF) focuses on monitoring rather than intervention, making it less immediately protective compared to preventing infection through asepsis.
B: Maintain hyper-oxygenation through use of a ventilator addresses oxygenation but does not directly prevent infection or complications specific to ventriculostomy care.
D: Administer IV mannitol (Osmitrol) provides medical management for ICP reduction but is secondary to preventing infection risks associated with ventriculostomy dressings.
A nurse is preparing to administer 0.9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Rationale:
The IV pump should infuse the 1-L bag of 0.9% sodium chloride over 5 hours.
At a rate of 200 mL/hr, dividing the total volume (1000 mL) by the rate (200 mL/hr) results in 5 hours. This calculation ensures the infusion is delivered safely and effectively to manage rhabdomyolysis by maintaining proper hydration without fluid overload.
B: 4 Calculating 4 hours underestimates the infusion duration, which would increase the infusion rate beyond 200 mL/hr, risking fluid overload and compromising patient safety in rhabdomyolysis management.
C: 10 Infusing over 10 hours would halve the intended rate, slowing hydration excessively and potentially delaying necessary fluid replacement critical for treating rhabdomyolysis.
D: 2 Two hours would require a rate of 500 mL/hr, far exceeding the prescribed 200 mL/hr, increasing risks of fluid overload and cardiovascular strain during treatment.
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Rationale:
Placing the client's bed at the lowest height helps prevent falls and injuries, which is crucial for clients with dementia who may have impaired judgment and mobility. This safety measure reduces the risk of harm during nighttime wandering or attempts to get out of bed independently, thereby promoting a safer environment tailored to their cognitive challenges and physical vulnerabilities.
B: Requesting a nightly sedative may increase fall risk and worsen confusion in dementia clients, potentially leading to adverse effects rather than improving safety or overall well-being during nighttime hours.
C: Assisting with toileting every 4 hours might be insufficient for dementia clients who often need more frequent assistance to prevent incontinence and reduce fall risk from urgent toileting needs.
D: Turning off all lights at night can cause disorientation and increase fall risk in dementia clients who benefit from low-level lighting to navigate safely and reduce confusion during nighttime awakenings.
The nurse is performing a neurological assessment on the older adult. An expected finding is that:
Rationale:
Older adults are more likely to lose short-term memory first. Age-related neurological changes often affect the hippocampus and prefrontal cortex, areas responsible for short-term memory processing, making it common for older adults to experience mild forgetfulness with recent events while long-term memory remains relatively intact.
B: Older adults have increased reflexes Reflex responses typically diminish due to age-related nerve conduction slowing and muscle changes, so increased reflexes are uncommon and not characteristic of normal aging neurological assessments.
C: Older adults have increased fine motor movement Fine motor skills generally decline with aging because of decreased muscle strength and nerve function, making enhanced fine motor movement an unlikely finding in neurological evaluations.
D: Older adults are more likely to lose long-term memory first Long-term memory tends to be preserved longer in aging, as it relies on different brain structures than short-term memory, which is more vulnerable to age-related decline.
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
Rationale:
Pooling of blood and edema around the eyes is an expected finding with a basilar skull fracture. This symptom, known as "raccoon eyes," results from blood tracking into the periorbital tissues due to fracture of the anterior cranial fossa. It indicates underlying cranial injury and possible dural tear, aiding nurses in identifying the severity and location of the fracture.
B: Ability to recall how the injury occurred does not specifically relate to basilar skull fractures, as memory retention depends on brain injury severity, not fracture type. It is unrelated to physical signs of basilar skull trauma.
C: Bruising over the mastoid process refers to Battle’s sign, indicating basilar skull fracture but is less common and later appearing than periorbital ecchymosis, making it a less immediate or anticipated finding.
D: Chvostek's sign involves facial muscle twitching from hypocalcemia, unrelated to basilar skull fractures. It is primarily associated with parathyroid dysfunction, not traumatic cranial injuries, and thus is not expected.
Which principle(s) would be included when teaching a patient to use a steroid inhaler? (Select All that Apply.)
Rationale:
Rinse and spit after inhalation of the medication, bronchodilators should be administered before steroid inhalers, frequent oral hygiene is necessary, and holding the breath for 10 seconds during inhalation of the medication are all essential principles when teaching a patient to use a steroid inhaler.
A: Rinsing and spitting help prevent oral thrush by removing residual steroid medication, reducing local side effects and promoting better oral health after inhaler use.
B: Administering bronchodilators before steroid inhalers opens airways, enhancing steroid medication delivery and effectiveness, optimizing therapeutic outcomes for respiratory conditions.
D: Frequent oral hygiene prevents infections and irritation caused by steroid residue, maintaining oral mucosa integrity and reducing the risk of complications during inhaler therapy.
E: Holding the breath for 10 seconds allows deeper medication deposition in the lungs, improving absorption and maximizing the anti-inflammatory effects of the steroid inhaler.
C: The inhaler is not used on a PRN basis only; steroid inhalers require regular use for maintenance therapy, not just symptom relief as needed.
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching?
Rationale:
A nurse teaching a client with a hiatal hernia should emphasize consuming less caffeine and fewer spicy foods, avoiding weight gain, and drinking fewer fluids. These measures help reduce acid reflux and esophageal irritation, which are common symptoms associated with hiatal hernias. Managing diet and lifestyle effectively minimizes discomfort and prevents worsening of the condition, improving the client’s quality of life.
C: I will lie down for one half hour after meals Such behavior can exacerbate reflux symptoms by allowing stomach contents to move upward into the esophagus, increasing discomfort and potentially causing more damage to the esophageal lining. Remaining upright is recommended to aid digestion and reduce reflux episodes.
Nurses' Notes
Day 1:
1000:
Client is alert to person, place, and time. Client is short of breath and leans forward to breathe easier. Lung sounds are diminished in bilateral bases with occasional wheezes. Nonproductive cough. Heart rate is regular. +2 pulses in all extremities.
1500:
Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Heart rate is regular. +2 pulses in all extremities. Client is oriented to person, place and time. Client is restless. Pupils are reactive to light. Client is diaphoretic with cyanotic mucous membranes
Vital Signs
1000:
Temperature: 37.1°C (98.8°F)
Heart Rate: 100/min
Respiratory Rate: 22/min (irregular)
Blood Pressure: 164/80 mm Hg
Oxygen Saturation: 92% on room air
1500:
Temperature: 37.3°C (100.3°F)
Heart Rate: 110/min
Respiratory Rate: 26/min (irregular)
Blood Pressure: 110/58 mm Hg
Oxygen Saturation: 87% on room air
A nurse is caring for a client who has COPD. Select the findings below that require immediate follow-up.
Rationale:
The findings that require immediate follow-up are: Client is restless, tachypneic with a productive cough, mucous is yellow, and wheezes and crackles.
These symptoms indicate worsening respiratory status and possible infection or hypoxia. Restlessness signals cerebral hypoxia, increased respiratory rate and productive cough suggest exacerbation, yellow mucous implies infection, and abnormal lung sounds confirm compromised airway function requiring urgent intervention.
A: Pulses in all extremities reflect adequate peripheral circulation and do not indicate acute distress.
D: Orientation to person, place, and time shows intact cognitive function, which does not suggest immediate deterioration.
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
Rationale:
Cardiac enzymes help determine the degree of damage to the heart tissues. These enzymes are released into the bloodstream when heart muscle cells are injured, providing critical information about the extent of myocardial damage following an acute MI. Elevated enzyme levels correlate with the severity of tissue injury, guiding treatment decisions and prognosis assessments in cardiac care.
A: Cardiac enzymes will identify the location of the MI. Enzyme levels indicate damage presence, not the precise anatomical location of the myocardial infarction. Imaging techniques are required for localization.
B: These tests will enable the provider to determine the heart structure and mobility of the heart valves. Cardiac enzyme studies do not evaluate structural or valvular function, which require echocardiography or other imaging modalities.
C: Cardiac enzymes assist in diagnosing the presence of pulmonary congestion. Pulmonary congestion is assessed through clinical signs and imaging, not by measuring cardiac enzyme levels in the blood.
A nurse is educating a group of clients about complementary and integrative therapies. Which of the following statements about these therapies are accurate?
Rationale:
Complementary therapies are used alongside conventional treatments to improve overall well-being. These therapies enhance patient care by supporting physical, emotional, and mental health without replacing standard medical interventions. They aim to integrate holistic approaches with traditional medicine, promoting healing and symptom management, thereby improving quality of life and patient satisfaction during treatment processes.
A: Meditation is a complementary therapy focusing on mental relaxation and stress reduction, not the use of medications. It emphasizes mindfulness techniques rather than pharmaceutical interventions, making this description inaccurate.
F: Integrative therapies complement rather than substitute conventional treatments. They are designed to work alongside standard care, enhancing therapeutic outcomes without replacing established medical protocols or medications.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Rationale:
Encouraging the client to drink 2 to 3 L of water daily helps thin bronchial secretions, making them easier to expectorate. Adequate hydration decreases mucus viscosity, facilitating clearance and reducing airway obstruction in clients with COPD, which addresses the client’s difficulty in bringing up secretions effectively.
A: Maintaining a semiFowler's position as often as possible improves lung expansion but does not directly thin mucus or aid secretion clearance.
B: Administering oxygen at 2 L/min supports oxygenation but does not influence mucus consistency or promote expectoration of secretions.
D: Helping the client select a low-salt diet manages fluid retention but does not specifically reduce mucus thickness or enhance sputum clearance.
A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Rationale:
Place the client in a protective environment.
This action is appropriate because clients with Clostridium difficile require isolation to prevent spreading the infection. A protective environment with contact precautions minimizes transmission risk through contaminated surfaces or direct contact, ensuring safety for other patients and healthcare workers. Such isolation protocols are essential in managing contagious gastrointestinal infections effectively within healthcare settings.
B: Clean surfaces with chlorhexidine. Chlorhexidine lacks efficacy against C. difficile spores, which require sporicidal agents like bleach for decontamination.
C: Wash hands with alcohol-based hand rub. Alcohol-based rubs do not eliminate C. difficile spores effectively; handwashing with soap and water is necessary to physically remove spores.
D: Obtain a stool specimen with gloves. While glove use is essential, this action alone does not address infection control comprehensively or prevent environmental contamination like isolation does.
A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?
Rationale:
The statement "My vision will slowly be restored after I start using the eye drops" requires reinforcement of education by the nurse. Vision loss from macular degeneration is typically irreversible, and current treatments do not restore vision but may slow progression. Eye drops are not a standard treatment, so expecting vision restoration from them reflects a misunderstanding that needs correction.
A: I will incorporate foods rich in vitamin C in my diet. This reflects accurate knowledge, as vitamin C is an antioxidant that can help reduce macular degeneration progression when included in a balanced diet.
B: I will receive injections into my eye. This is valid for certain types of macular degeneration, especially wet AMD, where anti-VEGF injections help control abnormal blood vessel growth and preserve remaining vision.
D: My vision will become progressively more blurry. This is true since macular degeneration causes gradual central vision loss, leading to increasing blurriness over time, indicating proper understanding of disease progression.
You arrive for your 7 a.m. shift on the urology unit and the night nurse gives a report on the following patients who will be under your care. Which one would you see first?
Rationale:
Mr. Bradford is 3 days post-radical prostatectomy for invasive bladder cancer.
Mr. Bradford requires immediate attention due to his recent major surgery, which carries risks of complications such as bleeding, infection, or urinary retention. Early postoperative assessment is crucial to identify and manage these potential issues promptly, ensuring patient safety and recovery. This priority surpasses patients in more stable or less acute phases of care.
A: Mr. Dominic, newly admitted for evaluation of bladder cancer. This patient’s condition is diagnostic and stable, lacking urgent postoperative risks, making immediate assessment less critical than a recent surgery patient.
C: Mr. Jennings had a TURBT yesterday. Although post-procedure, this patient is less likely to have life-threatening complications compared to one recovering from major surgery, lowering priority.
D: Ms. Griffiths, who had a cystectomy for bladder cancer 3 years ago. Being a long-term postoperative patient, she is stable and requires routine care rather than urgent evaluation.
During your physical examination of a 29-year-old professional volleyball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a 'tent' shape and slowly returns to its normal position. This is a sign of
Rationale:
Pinching the skin and observing it remain in a 'tent' shape that slowly returns to normal indicates dehydration. This decreased skin turgor reflects reduced fluid volume in the interstitial spaces, common after intense physical activity. Dehydration diminishes skin elasticity because of fluid loss, especially in athletes exposed to heat and exertion, confirming insufficient hydration status.
B: Hypervolemia involves excess fluid in the body, which increases skin turgor and elasticity, opposite to the observed slow skin recoil in this patient.
C: Properly hydrated skin quickly returns to its normal position after pinching, demonstrating normal elasticity, unlike the delayed return seen in this case.
D: Infection typically presents with redness, swelling, or warmth rather than changes in skin turgor or delayed skin recoil after pinching.
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?
Rationale:
Minimizing sun exposure reduces the risk for future BCC. This information is essential because ultraviolet (UV) radiation from the sun is a primary cause of basal cell carcinoma. Educating patients on protective measures like using sunscreen, wearing protective clothing, and avoiding peak sunlight hours helps prevent recurrence and new lesions, supporting long-term skin health and reducing cancer risk.
A: Screening for metastasis will be important. Basal cell carcinoma rarely metastasizes, so extensive metastasis screening is generally unnecessary in typical cases, making this less relevant for the teaching plan.
C: The treatment plan includes watchful waiting. BCC usually requires active treatment such as excision; watchful waiting is not a standard approach due to potential local tissue damage.
D: Low-dose systemic chemotherapy is used to treat BCC. Systemic chemotherapy is uncommon for BCC, as localized treatments like surgery or topical therapies are typically sufficient for management.
A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site. Which of the following actions should the nurse take?
Rationale:
Assess pulses in the client's affected arm. Monitoring pulses ensures adequate blood flow and detects complications such as arterial occlusion or hematoma after a left-sided cardiac catheterization with an upper extremity insertion. Early identification of vascular compromise is crucial to prevent ischemic injury and guide timely intervention, promoting patient safety and optimal recovery during post-procedure assessment.
A: Encourage the client to ambulate within 30 min following the procedure Risks of early ambulation include dislodging clots or causing bleeding at the insertion site, making immediate mobilization unsafe after upper extremity catheterization.
B: Keep the client NPO for at least 2 hr following the procedure NPO status is generally unnecessary after catheterization once hemodynamic stability is confirmed; nutrition does not affect vascular site integrity.
D: Apply light pressure to the insertion site Continuous pressure is unnecessary post-procedure; firm, sustained pressure is typically required to prevent bleeding, but light pressure alone does not adequately control hemostasis.
The nurse is caring for a client post-thyroidectomy that is showing clinical manifestations of hypocalcemia. Which of the following would the nurse expect to find during the assessment?
Rationale:
Positive Chvostek's sign is indicative of hypocalcemia, characterized by facial muscle twitching when the facial nerve is tapped. This clinical manifestation occurs due to increased neuromuscular excitability caused by low calcium levels following thyroidectomy, which can affect parathyroid gland function and calcium regulation, making it a key diagnostic sign in this context.
A: Dilated pupils typically result from neurological or pharmacological causes and are unrelated to hypocalcemia. This symptom does not reflect the neuromuscular irritability seen in calcium deficiency states post-thyroidectomy.
B: Hyperactive bowel sounds are more commonly associated with gastrointestinal disturbances, not hypocalcemia. Hypocalcemia primarily affects neuromuscular function rather than causing increased intestinal motility.
C: Hyperglycemia involves elevated blood glucose levels, which is unrelated to calcium imbalance. Hypocalcemia influences neuromuscular irritability rather than glucose metabolism, so this symptom is irrelevant in this context.
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
Rationale:
A breathing exercise with a longer inhalation phase helps improve ventilation and oxygen exchange in clients with emphysema. This technique promotes better lung expansion and reduces air trapping, which is essential in managing emphysema's characteristic airflow limitation and hyperinflation, thereby enhancing respiratory efficiency and patient comfort.
A: Limiting fluid intake to 1,000 mL per day is inappropriate as hydration helps thin mucus and facilitates expectoration, which is beneficial in emphysema management.
B: Administering oxygen at 2 L/min may cause hypoventilation in emphysema patients due to their reliance on hypoxic drive; oxygen therapy must be carefully titrated.
C: Incentive spirometry focuses on deep inhalation but emphysema primarily involves difficulty with exhalation and air trapping, making this intervention less effective for symptom relief.
The nurse is presenting a community health program on fracture risk reduction. Which topics should be included? (SELECT ALL THAT APPLY)
Rationale:
The topics that should be included are Use of seatbelts, Osteoporosis screening, Use of helmets, and Fall prevention.
B: Use of seatbelts reduces injury risk during vehicle accidents, directly lowering fracture chances. This safety measure is crucial in preventing traumatic fractures caused by collisions or sudden impacts in community settings.
C: Osteoporosis screening helps identify individuals at higher fracture risk due to decreased bone density, allowing early intervention. Addressing bone health is fundamental in fracture risk reduction through timely diagnosis and treatment.
D: Use of helmets protects the head from injury during activities like biking or sports, preventing fractures in the skull and face. Helmets are a vital protective gear to reduce impact-related fractures.
E: Fall prevention is essential because falls are a leading cause of fractures, especially among older adults. Education on home safety and balance exercises lowers fracture incidence by minimizing fall risk.
A: Effects of recreational drug use focus on substance impact, not directly on fracture prevention measures; thus, it is unrelated to fracture risk reduction content in this context.
A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
Rationale:
Use a raised toilet seat to maintain your hips above your knees.
This statement is correct because maintaining hip flexion less than 90 degrees after total hip arthroplasty reduces dislocation risk. A raised toilet seat helps keep proper hip alignment during sitting, preventing excessive bending and promoting safe healing. This precaution is essential for postoperative care and patient safety in daily activities like toileting.
A: Twist at the waist when standing from a seated position. Twisting can cause hip dislocation by placing stress on the surgical site, making this movement unsafe during recovery.
B: Move your stronger leg first when using a walker. Leading with the weaker leg is safer to support weight correctly and avoid falls, so this advice contradicts standard postoperative mobility guidance.
D: Apply a heating pad to the operative hip to decrease pain. Heat can increase swelling and inflammation post-surgery; cold therapy is generally recommended instead to manage pain and reduce edema.
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?
Rationale:
0.9% sodium chloride IV bolus
Administering a 0.9% sodium chloride IV bolus is essential in diabetic ketoacidosis to rapidly restore intravascular volume and correct dehydration caused by osmotic diuresis. This isotonic solution helps stabilize hemodynamics and improve renal perfusion, facilitating glucose and ketone excretion. Prompt fluid resuscitation prevents hypovolemic shock and supports metabolic recovery in severe hyperglycemia cases.
A: Glucocorticoid medications Glucocorticoids raise blood glucose levels by promoting gluconeogenesis, potentially worsening hyperglycemia and diabetic ketoacidosis rather than treating the acute metabolic crisis.
B: Dextrose 5% in 0.45% sodium chloride This hypotonic solution is inappropriate initially because it may exacerbate cellular swelling and does not provide adequate volume resuscitation in severe dehydration.
C: Oral hypoglycemic medications Oral agents are ineffective in acute DKA management and contraindicated due to delayed onset and inability to rapidly reduce critically elevated blood glucose levels.
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
Rationale:
Maintaining stable blood glucose levels helps prevent the progression of diabetic retinopathy and nephropathy by reducing damage to blood vessels in the eyes and kidneys. Consistent glucose control minimizes microvascular complications, preserving organ function and slowing disease development. This is a primary preventive strategy for long-term diabetes-related complications, emphasizing the importance of glycemic management in overall care plans.
A: Wear compression stockings daily. Compression stockings primarily aid in preventing venous insufficiency and edema, not specifically targeting diabetic retinopathy or nephropathy prevention. They do not influence microvascular damage caused by diabetes.
B: Examine your feet carefully every day. Daily foot examinations help prevent diabetic foot ulcers and infections, unrelated to preventing eye or kidney complications associated with diabetes.
D: Have an eye examination once per year. Annual eye exams detect retinopathy early but do not actively prevent the onset or progression of retinopathy or nephropathy like maintaining stable blood glucose does.
The nurse is caring for a client after a total thyroidectomy. The nurse's priority should be to:
Rationale:
The nurse's priority is to maintain the client in a Fowler's position, with head neutral supported by pillows. This position reduces neck tension, promotes airway patency, prevents edema, and facilitates drainage of secretions after thyroidectomy, minimizing respiratory complications and ensuring comfort while protecting the surgical site from strain or injury during the critical postoperative period.
A: Encourage the client to cough and deep breathe every two hours, with her neck in a flexed position. Flexing the neck increases tension on the surgical site, risking wound disruption and hemorrhage, making this approach unsuitable immediately after thyroidectomy.
C: Maintain the client in a supine position, with sandbags placed on either side of her head and neck. Supine positioning can increase swelling and airway obstruction risk, while sandbags restrict movement, potentially causing discomfort and compromising circulation.
D: Encourage the client to turn head side to side, to promote drainage of oral secretions. Turning the head side to side may strain the incision area, increasing the possibility of bleeding or damage to the delicate surgical site post-thyroidectomy.
Cardiogenic shock occurs when the heart's pumping ability is compromised. What can impair the pumping ability of the heart? Select all that apply.
Rationale:
Cardiogenic shock can be caused by myocardial infarction, cardiac tamponade, severe bradycardia, tension pneumothorax, and massive pulmonary embolism.
Myocardial infarction damages heart muscle, reducing contractility and output. Cardiac tamponade compresses the heart, limiting filling and stroke volume. Severe bradycardia slows heart rate, decreasing cardiac output. Tension pneumothorax impairs venous return and ventricular filling. Massive pulmonary embolism obstructs pulmonary circulation, increasing right heart strain and reducing left ventricular preload.
A: Myocardial infarction damages heart muscle, directly inhibiting contraction and reducing effective pumping capacity, leading to cardiogenic shock.
B: Cardiac tamponade restricts heart expansion due to fluid accumulation, diminishing ventricular filling and output, causing pump failure.
C: Severe bradycardia slows heart rate excessively, lowering cardiac output insufficient to meet systemic demands, impairing pump function.
D: Tension pneumothorax increases intrathoracic pressure, compressing heart and great veins, decreasing preload and cardiac output significantly.
E: Massive pulmonary embolism blocks pulmonary arteries, elevating right ventricular pressure and decreasing left ventricular filling and effective pumping.
Prescription Order: 1g in 50 mL to infuse over 30 minutes; gtt factor= 15gtts/1mL. How many drops per minute will you infuse?
Rationale:
25 drops per minute. Calculating the drops per minute requires dividing the total volume (50 mL) by the infusion time (30 minutes), resulting in 1.67 mL/min. Multiplying by the drop factor (15 gtts/mL) yields 25 drops per minute. This precise calculation ensures accurate medication delivery consistent with the prescribed rate, avoiding under- or overdosing complications.
A: 15 drops per minute Underestimates the infusion rate by using a smaller volume-to-time ratio, leading to insufficient medication delivery and potential therapeutic failure due to slower infusion than prescribed.
B: 30 drops per minute Overestimates the infusion rate by increasing drops per minute beyond the calculated value, risking overdose and adverse effects from administering the medication too quickly.
C: 50 drops per minute Significantly exaggerates the drops per minute, which would result in a dangerously rapid infusion, compromising patient safety and violating the prescribed infusion protocol.
A client is to receive 500 mL of IV fluid over 8 hours. At what rate should the nurse set the IV pump?
Rationale:
The nurse should set the IV pump to 62.5 mL/h.
Dividing 500 mL by 8 hours calculates the precise infusion rate: 500 ÷ 8 = 62.5 mL per hour. This ensures the client receives the correct total volume evenly over the designated time frame, preventing under- or over-infusion and maintaining fluid balance as prescribed.
A: 40 mL/h Underestimates the rate, resulting in insufficient fluid delivery over 8 hours.
B: 50 mL/h Delivers less than the required amount, risking incomplete infusion within the timeframe.
C: 125 mL/h Doubles the needed rate, potentially causing fluid overload and adverse effects.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
Rationale:
A decrease in cardiac output in a client with left-sided heart failure is indicated by dyspnea. Dyspnea results from pulmonary congestion due to the heart's inability to effectively pump blood, causing fluid buildup in the lungs. This respiratory distress directly reflects compromised cardiac function and reduced oxygen delivery, signaling diminished cardiac output in left-sided heart failure patients.
A: Weight gain Weight gain primarily reflects fluid retention and volume overload, common in right-sided heart failure or overall fluid imbalance, but is not a direct indicator of decreased cardiac output in left-sided heart failure.
B: Distended abdomen Distended abdomen suggests ascites or fluid accumulation associated mainly with right-sided heart failure or liver congestion, not a direct consequence of reduced cardiac output from left-sided heart failure.
C: Confusion Confusion typically arises from cerebral hypoxia or electrolyte imbalances but is a nonspecific symptom that does not directly indicate decreased cardiac output in left-sided heart failure.
A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care?
Rationale:
All listed interventions—administering pain medication as needed, maintaining ventriculostomy position, keeping the neck midline, elevating the head of the bed, and maintaining enteral feedings—should be included in the care plan for a client with a traumatic brain injury.
Administering pain medication helps control pain without increasing intracranial pressure, essential for TBI care. Maintaining ventriculostomy position ensures accurate cerebrospinal fluid drainage. Keeping the neck midline prevents jugular vein compression, promoting venous drainage. Elevating the head reduces intracranial pressure. Enteral feedings provide adequate nutrition to support healing.
A: Administer pain medication as needed. This option is correct, so it’s not explained here as incorrect.
B: Maintain ventriculostomy at the correct position. This is also correct and serves to monitor and control intracranial pressure.
C: Maintain the neck in the midline position. This position facilitates venous return and prevents increased intracranial pressure.
D: Elevate the head of the bed to 150. Elevating the head of the bed should be to 30 degrees, not 150, to effectively reduce intracranial pressure.
E: Maintain enteral feedings. Enteral feeding supports nutritional status, essential for recovery and preventing secondary complications in TBI patients.
A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect?
Rationale:
Bradycardia typically causes lightheadedness due to decreased cardiac output and reduced cerebral perfusion. This symptom arises as the heart rate slows, limiting oxygen delivery to the brain. Clients often experience dizziness or faintness. The nurse should expect lightheadedness as a direct consequence of the impaired circulation associated with bradycardia, reflecting the heart’s insufficient pumping capacity.
A: Anxiety does not directly result from bradycardia; it more commonly relates to psychological or stress factors rather than the physical impact of a slow heart rate. Anxiety is not a typical physiological response in this context.
C: Elevated temperature is unrelated to bradycardia since heart rate changes do not typically influence body temperature regulation or indicate infection or inflammation. Fever is caused by other underlying conditions.
D: Fluid deficit involves decreased body fluids, which primarily affects blood volume, not the heart rate directly; bradycardia stems from conduction system issues, not from fluid status abnormalities.
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which nursing action should the nurse complete first?
Rationale:
Pulse and respirations should be assessed first before percussion, vibration, and postural drainage. Monitoring vital signs establishes a baseline, ensuring the adolescent’s cardiopulmonary status is stable enough for the procedure, and helps detect any distress or contraindications prior to initiating therapy, promoting client safety throughout the intervention.
A: Assess characteristics of sputum provides information about secretions but does not address immediate respiratory or cardiovascular stability before treatment.
C: Instruct to slowly exhale with pursed lips is a breathing technique more relevant during or after therapy, not as an initial preparatory step.
D: Auscultate lung fields offers important respiratory assessment data but does not directly evaluate overall vital sign stability essential prior to the procedure.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
Rationale:
The client expresses immediate relief.
This option signifies that the pericardiocentesis successfully alleviated the pressure on the heart caused by cardiac tamponade, restoring normal cardiac function and improving symptoms such as chest discomfort and shortness of breath. Immediate relief reflects effective drainage of excess fluid, which directly reduces cardiac compression and enhances hemodynamic stability.
A: Muffled heart sounds indicate ongoing fluid accumulation or compression, which contradicts improvement after the procedure.
B: Jugular venous distention shows persistent venous pressure elevation, suggesting unresolved cardiac tamponade or ineffective fluid removal.
C: Client reports dyspnea reflects continuing respiratory distress, meaning the pericardiocentesis did not sufficiently relieve cardiac or pulmonary compromise.
The nurse is planning a teaching session for a patient with a duodenal ulcer. Which instructions are MOST important to include in the teaching? (SELECT ALL THAT APPLY)
Rationale:
Avoid aspirin products, start a smoking cessation program, and avoid ibuprofen for pain are the most important instructions to include in the teaching for a patient with a duodenal ulcer. These actions help prevent further irritation and damage to the ulcerated duodenal lining by reducing exposure to substances that increase gastric acid or impair mucosal protection, promoting healing and preventing complications.
B: Choose regular coffee instead of herbal tea does not benefit ulcer healing; caffeine can increase stomach acid, potentially worsening symptoms, making this an unhelpful recommendation for duodenal ulcer management.
C: Eat a diet rich in dairy products is outdated advice; excessive dairy may stimulate acid secretion, exacerbating ulcer symptoms rather than providing healing benefits or symptom relief.