Exam 3 Prep U's Flashcards
1
Q
A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client?
A
Age
Explanation:
Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and dyslipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.
2
Q
A nurse is planning care for a client who will be arriving to the unit postoperatively from bariatric surgery. In an effort to decrease the risk of venous thromboembolism (VTE), which health care provider orders does the nurse anticipate?
A
Mechanical compression and prophylactic anticoagulation
Explanation:
Both mechanical compression (intermittent pneumatic compression devices) and prophylactic anticoagulation with low molecular weight heparin agents are prescribed in the client who is postoperative bariatric surgery. Early ambulation is encouraged; however, it is not the only intervention.
3
Q
A client weighs 215 lbs and is 5’ 8” tall. The nurse calculate this client’s body mass index (BMI) as what?
A
32.7
Explanation:
Using the formula for BMI, the client’s weight in pounds (215) is divided by the height in inches squared (68 inches squared) and then multiplied by 703. The result would be 32.7.
4
Q
A nurse cares for a female client of childbearing age who will undergo bariatric surgery. When teaching the client about precautions after surgery, which teaching will the nurse include that is specific to this population?
A
“You should avoid pregnancy for at least 18 months after surgery.”
Explanation:
When teaching a female of childbearing age regarding precautions after bariatric surgery, the nurse should instruct the client to avoid pregnancy for at least 18 months after surgery. The ability to conceive after weight loss surgery may improve more often than worsen. Contraceptives are no less effective after surgery than before.
5
Q
A nurse epidemiologist examines the overall decrease in life expectancy related to obesity. What finding is true?
A
There is a 6-20 year decrease in overall life expectancy for those with obesity.
Explanation:
Overall, there is a 6-20 year decrease in overall life expectancy for those with obesity.
6
Q
A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply. Hyperlipidemia Gender Obesity Race Tobacco use
A
Hyperlipidemia
Obesity
Tobacco use
7
Q
What pathophysiological concept is related to the increase in the hormone leptin, as it relates to satiety and hunger?
A
Increased adipose stores
Explanation:
Increased fat stores increases the level of leptin in the bloodstream.
8
Q
A nurse cares for clients with obesity. Which clinical measurements use quantified measurements to diagnose obesity? Select all that apply. Blood pressure Total cholesterol Weight BMI Waist circumference
A
Weight
BMI
Waist circumference
9
Q
A client with obesity is prescribed orlistat for weight loss. The client asks the nurse, “I understand the medication prevents digestion of fat, but what happens if I eat fat?” What is the nurse’s best response?
A
“The fat is passed in your stools.”
Explanation:
Orlistat (Xenical) prevents the absorption of 30% of fat, decreasing caloric intake. Undigested fat is passed in the stools. The undigested fat is not excreted in the urine, absorbed in the intestines, or left undigested in the stomach.
10
Q
A nurse cares for a client who is obese. The health care provider prescribes orlistat in an effort to help client lose weight, along with diet and exercise. When teaching the client about this medication, what will the nurse include?
A
“It binds with enzymes to help prevent digestion of fat.”
Explanation:
Orlistat (Xenical) works to bind to gastric and pancreatic lipase to prevent the digestion of 30% of ingested fat, thereby decreasing caloric intake.
11
Q
The nurse provides care to a menopausal client, who states, “I read a news article that says I am at risk for coronary vascular disease due to inflammation.” Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?
A
Addressing obesity
Explanation:
The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.
12
Q
The nurse is teaching injection techniques for a client prescribed liraglutide for the treatment of obesity. Which areas of the body will the nurse suggest for injection sites? Select all that apply. Upper thigh Abdomen Upper arm Buttocks Lower thigh
A
Upper thigh
Abdomen
Upper arm
Lower thigh
13
Q
A client with obesity is prescribed lorcaserin for weight loss. The client reports dry mouth. What is the nurse’s best response?
A
“This is an expected finding with this medication.”
Explanation:
Lorcaserin (Belviq), a selective serotonergic 5-HT2C receptor agonist, causes dry mouth. This is an expected and normal finding. Increasing fluid intake does not make this symptom go away. The other answer choices are incorrect.
14
Q
The nurse is teaching a group of clients with obesity about the risks of disease associated with obesity. Which respiratory conditions or diseases will the nurse include in the teaching, which are associated with obesity? Select all that apply. Asthma Infection Obstructive sleep apnea Central sleep apnea Emphysema
A
Asthma
Infection
Obstructive sleep apnea
15
Q
A nurse cares for an obese client taking phentermine for weight loss. What client teaching will the nurse include when discussing precautions about the medication?
A
“Do not drink alcohol while taking this medication.”
Explanation:
The nurse should tell the client to avoid drinking alcohol while taking this medication. The other answer choices are not as important as avoiding the drug/alcohol interaction associated with this medication.
16
Q
The nurse observes that a client’s medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client’s BMI is 31, waist circumference is 40 inches, and localized fat pads exist around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the client’s care?
A
The nurse recognizes that the client’s obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment.
Explanation:
Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these symptoms should be studied further. Food records, 24-hour diet recall, and dietary education directed at weight loss do not account for the client’s medical condition as a factor in the client’s weight or nutritional status, although each method helps estimate whether food intake is adequate and appropriate.
17
Q
A client with obesity is diagnosed with type 2 diabetes. In order to promote weight loss in the client and aid in glucose management, which medication will the nurse anticipate the health care provider ordering?
A
Metformin
Explanation:
Metformin (Glucophage) is a diabetes medication that also promotes weight loss. The other medications are diabetes medications; however, these promote weight gain, not weight loss.
18
Q
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
A
“I should become involved in a weight loss program.”
Explanation:
Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won’t alleviate sleep apnea, and the physician probably wouldn’t order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren’t treatment factors associated with sleep apnea.
19
Q
A nurse cares for a client who is post op bariatric surgery. Which position will the nurse place the client in order to best promote comfort?
A
Low Fowler’s
Explanation:
Positioning the client in low Fowler’s position best promotes comfort in the client who is post op bariatric surgery. In addition to decreasing incisional pain, this position also promotes gastric emptying.
20
Q
A nurse cares for clients who undergo bariatric surgery due to obesity. When teaching the client on the most successful surgery in clients with very high BMI’s, which procedure will the nurse mention?
A
Biliopancreatic diversion with duodenal switch
Explanation:
The biliopancreatic diversion with duodenal switch is the most successful bariatric surgery for clients with the highest BMI’s. The other answer choices represent additional bariatric surgeries; however, these are not the most successful in clients with the highest BMI’s.
21
Q
Which hormones released throughout the gastrointestinal tract promote satiety? Select all that apply. Somatostatin Cholecystokinin Insulin Ghrelin Neuropeptide y
A
Somatostatin, cholecystokinin, and insulin are all hormones released throughout the gastrointestinal tract that promote satiety. Ghrelin and neuropeptide y are orexigenic, and stimulate hunger.
22
Q
A nurse researches the cost and financial impact of obesity in America. What is the annual health care cost tied to obesity?
A
$147 billion
Explanation:
The estimated annual health care costs in America tied to obesity is $147 billion.
23
Q
A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse’s understanding of the primary reason for this finding?
A
Rapid gastric dumping
Explanation:
Rapid gastric dumping may lead to steatorrhea, excessive fat in the feces. The primary cause of this finding is rapid gastric dumping. Excessive fat intake can make the problem worse; however, this is not the primary cause of the symptoms. Steatorrhea results from increased motility, not decreased and the size of the stomach does not contribute to this finding.
24
Q
A nurse researcher studies the pathophysiology and etiology of obesity. What does the nurse discover is true regarding the “thrifty gene” theory of obesity?
A
Over time, we have become efficient in food storage and deposition of fat stores.
Explanation:
According to the “thrifty gene” theory, hunting for scarce food sources during prehistoric times consumed a lot of energy, and food sources were not abundant. Storing fat to provide energy sources during times of food scarcity was a physiologic adaptive response to these environmental challenges and over time, we became more efficient in food storage and fat deposition.
25
A client who is obese and the nurse have established a goal for the client to achieve a weight loss of 1 pound each week. One month later, the nurse evaluates that the client has lost 2 pounds. The nurse first states
"You have succeeded in making positive progress."
Explanation:
In the evaluation stage of the nursing process, the nurse validates even small increments toward goal achievement, as reflected in statement b. This is important for enhancement of client self–esteem and reinforcing client behavior. Change is a slow process, and success may be defined as making some progress. The nurse and client will then need to re–evaluate the goal, as in statement d, and either continue with the current goal, change the goal, or discontinue the goal. Statements a and c are negative criticisms and would diminish client self–esteem.
26
A client who is 6 months postoperative bariatric surgery tells the nurse, "I hate what my body looks like now. All these skin folds really bother me." What is the nurse's best response?
"You are not alone in having these feelings."
Explanation:
A client who is postoperative from bariatric surgery may share that they are dissatisfied with their appearance, often due to loose skin folds from excessive weight loss. It is the nurse's role to validate the client's feelings and to make sure the client understands that these feelings are normal. Asking the client why he or she is dissatisfied put the client in a defensive space and is not therapeutic. The client needs validation for his or her feelings; not being told that he or she can change. This may worsen the client's body image.
27
A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works?
Restricts the client's ability to eat.
Explanation:
Bariatric surgical procedures work by restricting a patient’s ability to eat (restrictive procedure), interfering with ingested nutrient absorption (malabsorptive procedures), or both. Bariatric procedures do not impair caloric absorption; rather, nutrients are impaired by malabsorption.
28
A nurse cares for a client with a BMI of 36 kg/m2 and nonalcoholic fatty liver disease. The client asks the nurse if he is a candidate for bariatric surgery. How should the nurse respond to the client?
"Yes, your BMI and chronic condition meets the criteria for bariatric surgery."
Explanation:
The client's BMI of > 35 kg/m2 and a more severe obesity-associated comorbid condition, makes the client a candidate for bariatric surgery.
29
Place the pathophysiological steps in order of how a client with obesity is at greater risk for venous thromboembolism in comparison to the general population.
Increased adipose tissue
Impairment of peripheral blood flow
Blood stasis
Formation of a thrombus
30
```
A nurse working in a cardiac health care office notes increased risk of certain cardiac conditions as a result of obesity. Which conditions can be associated with obesity? Select all that apply.
Hypertension
Coronary artery disease
Heart failure
Myocardial infarction
Heart murmur
```
Hypertension
Coronary artery disease
Heart failure
Myocardial infarction
31
Understanding the definition of eating disorders is important in communicating facts while managing these conditions. Which is not an eating disorder?
obesity
Explanation:
Anorexia nervosa, bulimia nervosa, binge eating, and compulsive overeating are eating disorders. Obesity is a consequence of overeating.
32
A nurse cares for a client who is 5 feet 11 inches tall and weighs 225 pounds. What statement describes the client's BMI?
Class I obesity
Explanation:
To calculate BMI, multiply weight in pounds by 703 and then divide that by height in inches squared. The client's BMI is 31.4 kg/m2. This falls under the Class I obesity category. Normal weight BMI is 18.5-25 kg/m2. Overweight BMI is 25-30 kg/m2. Class II obesity is a BMI 35-40 kg/m2.
33
The nurse plans care for a client with obesity. What does the nurse recognize is the primary pathophysiological reason clients with obesity are at greater risk for developing thromboembolism?
Compromised peripheral blood flow
Explanation:
A client with obesity is at increased risk for developing thromboembolism due to compromised blood flow and resulting venous stasis. Although the client with obesity is at risk for high cholesterol levels, increased fat in the blood does not directly impact the risk for developing thromboembolism. Increased blood viscosity and impaired clotting do not typically occur in obesity and are not the reason a client with obesity would be at greater risk for developing thromboembolism.
34
A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose?
Stimulate GI peristalsis
Explanation:
Early oral hydration stimulates GI peristalsis. The nurse would not give a client oral hydration to assess for intact swallowing as this may lead to aspiration. There is no reason to assume a client would have gastric perforation and this would not be appropriate. Digestive hormones are stimulated once peristalsis begins; however, this is not the primary purpose of early oral hydration.
35
The nurse establishes a learning contract with an overweight client. The contract is best if it
includes an incremental goal of 1–2 pound weight loss this week
Explanation:
The learning contract is recorded in writing. It is to be clear and describe what is to be achieved. A well–balanced diet is too vague. The nurse provides frequent and positive reinforcement as the client moves from one goal to the next. It is easier for the client to achieve a smaller, obtainable goal, such as 1–2 pound weight loss in one week, versus 30 pounds in 6 months.
36
A nurse researcher is reviewing data obtained from a developing nation on nutrition and metabolism issues facing that country. What is the nurse's understanding of the "double-burden" many developing nations now face?
Both undernutrition and obesity
Explanation:
The WHO mentions that many developing nations now face a double-burden of both undernutrition and obesity. Both of these issues occur simultaneously and create a public health burden to developing nations.
37
A client is scheduled for a Roux-en-Y bariatric surgery. When teaching the client about the surgical procedure, which statement will the nurse use?
"The stomach is stapled to create a very small pouch and part of the small intestine is rerouted."
Explanation:
In Roux-en-Y bariatric surgery, a horizontal row of staples across the fundus of the stomach creates a pouch with a capacity of 20 to 30 mL. The jejunum is divided distal to the ligament of Treitz, and the distal end is anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum.
38
A nurse caring for adults with obesity recognizes that obesity is classified based on BMI. Which BMI does the nurse recognize as Class II obesity?
35 kg/m2
Explanation:
Class I obesity is defined as 30-34.9 kg/m2. Class II obesity is defined as a BMI of 35-39.9 kg/m2. A BMI of 40 kg/m2 or greater defines Class III obesity.
39
A nurse is providing discharge instruction for a client who is postoperative bariatric surgery. What statement will the nurse include when providing teaching aimed at decreasing the risk of gastric ulcers?
"Avoid taking non-steroidal anti-inflammatory drugs."
Explanation:
The only statement that aids in avoiding gastric ulcers is the statement instructing the client to avoid taking non-steroidal anti-inflammatory (NSAID) drugs. Sitting in a semi-recumbent of low Fowler's position aids in digestion but does not aid in the prevention of gastric ulcers. Propping the head of the bed would be beneficial for a client report GERD or acid reflux. antacid drugs do not increase the risk of gastric ulcers.
40
A nurse reviews a client's medication list and notes the client takes orlistat for the treatment of obesity and to promote weight loss. Which client teaching will the nurse include that best promotes health in the client taking this medication?
"Make sure and take a daily multivitamin."
Explanation:
The nurse should advise the client taking orlistat (Xenical) to take a daily multivitamin (not just calcium) as the client is at risk for malabsorption of nutrients.
41
A client with obesity reports pain in the joints. Which musculoskeletal condition related to obesity does the nurse suspect the client has?
Osteoarthritis
Explanation:
Osteoarthritis is an obesity-related musculoskeletal condition. Rheumatoid arthritis, inflammatory arthritis, and necrotizing arthritis are not obesity-related conditions.
42
What is a characteristic of the intrarenal category of acute renal failure?
Increased BUN
Explanation:
The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.
43
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?
Fever
Explanation:
Fever is an indicator of infection or transplant rejection.
44
The client with polycystic kidney disease asks the nurse, “Will my kidneys ever function normally again?” The best response by the nurse is:
“As the disease progresses, you will most likely require renal replacement therapy.”
Explanation:
There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.
45
A patient undergoing a CT scan with contrast has a baseline creatinine level of 3 mg/dL, identifying this patient as at a high risk for developing kidney failure. What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)?
Hydrating with saline intravenously before the test
Explanation:
Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired AKI. This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify patients at high risk. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of CIN (Murphy & Byrne, 2010; Rank, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent CIN (Murphy & Byrne, 2010; Rank, 2013).
46
The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.
4000
Explanation:
A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.
47
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
“It is appropriate to warm the dialysate in a microwave.”
Explanation:
The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
48
The nurse is able to identify which condition as uremia?
An excess of urea in the blood
Explanation:
Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.
49
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage
Explanation:
If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.
50
The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of sodium polystyrene sulfonate [Kayexalate])
Explanation:
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
51
The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease.
When a client has an arteriovenous (AV) fistula for hemodialysis, the nurse must provide interventions to protect the fistula and assess its patency.
The nurse auscultates the AV fistula with a stethoscope to detect a bruit, a sound generated by turbulent blood flow. The absence of a bruit may indicate blockage or clotting of the fistula. Likewise, the nurse palpates the AV fistula for a thrill (vibration), indicating turbulent blood flow through the fistula. The absence of a thrill can indicate a blockage or clotting of the fistula. The nurse also assesses for redness, swelling, or drainage at the AV fistula that might indicate infection. Blood pressures should not be taken in the arm with an AV fistula. Inflation of the blood pressure cuff can reduce the flow of blood, resulting in the clotting of blood in the fistula. Likewise, a tourniquet should not be placed around the arm to draw blood and the AV fistula should not be wrapped with a compression dressing as these procedures decrease blood flow to the fistula and increase the risk of clot formation.
52
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
Explanation:
The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.
53
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
Increase carbohydrates and limit protein intake.
Explanation:
Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.
54
Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.
Citrus fruits
Explanation:
Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.
55
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of:
water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
Explanation:
The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
56
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute kidney injury. Which statement from the nurse best reflects the ability of the kidneys to recover from acute kidney injury?
The kidneys can improve over a period of months.
Explanation:
The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute kidney injury can progress to chronic renal failure.
57
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
Explanation:
Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
58
A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD?
The client has a history of diverticulitis.
Explanation:
A history of diverticulitis contraindicates CAPD because CAPD has been associated with the rupture of diverticulum. A history of severe anemia while on hemodialysis or being on the transplant waiting list doesn't contraindicate CAPD. The client who's blind or partially blind can still learn to perform CAPD.
59
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?
Cola-colored urine
Explanation:
Cola-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.
60
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
Recent history of streptococcal infection
Explanation:
Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.
61
What is used to decrease potassium level seen in acute renal failure?
Sodium polystyrene sulfonate
Explanation:
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
62
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem?
Sore throat 2 weeks ago
Explanation:
Acute glomerulonephritis usually occurs as a result of bacterial infection such as seen with a beta-hemolytic streptococcal infection or impetigo. Red blood cells and protein found in the urine and elevated blood pressure are symptoms associated with glomerulonephritis.
63
What is a hallmark of the diagnosis of nephrotic syndrome?
Proteinuria
Explanation:
Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.
64
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
Glomerulonephritis
Explanation:
Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.
65
A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys
Explanation:
Acute kidney injury can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.
66
A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?
114
Explanation:
To calculate the amount of protein the client is to ingest per day, first determine the client’s weight in kg by dividing the weight in lbs by 2.2 or 209/2.2 = 95 kg. Then multiply the client’s weight in kg by 1.2 or 95 x 1.2 = 114 grams. The client is to ingest 114 grams of protein per day.
67
The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:
1,500 mL of fluid
Explanation:
A 1-kg weight gain is equal to 1,000 mL of retained fluid.
68
```
Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply.
Hyperkalemia
Metabolic alkalosis
Anemia
Hyperalbuminemia
Hypocalcemia
```
Hyperkalemia is due to decreased potassium excretion and excessive potassium intake. Metabolic acidosis results from decreased acid secretion by the kidney. A damaged glomerular membrane causes excess protein loss.
69
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
Tall, peaked T waves
Explanation:
Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.
70
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urine output of 250 ml/24 hours
Explanation:
ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.
71
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20.
Explanation:
The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.
72
```
The client with prostatitis presents with low back pain, dysuria, and unusual sensation following ejaculation. Which treatment(s) does the nurse anticipate being prescribed? Select all that apply.
Analgesics
Sitz baths
Antibiotics
Abstinence
Treatment of sexual partner
```
Prostatitis is an inflammation of the prostate gland that is most often caused by microorganisms. Treatment consists of up to 30 days of antibiotic therapy, mild analgesics, and sitz baths. Sexual partners also need to be treated. Regular drainage of the prostate gland through masturbation or intercourse can be helpful in decreasing the inflammation and discomfort.
73
The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?
Brief, hot daily showers
Explanation:
Hot water removes more oils from the skin and can increase dryness and itching. Tepid water temperature is preferred in the management of pruritus. The use of moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid scratching and keeping nails trimmed short is indicated in the management of pruritus.
74
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?
Wear a mask when performing exchanges.
Explanation:
The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.
75
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?
Less than 400 mL
Explanation:
The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
76
The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client?
Keep the dialysis supplies in a clean area, away from children and pets
Explanation:
It is important to keep the dialysis supplies in a clean area, away from children and pets, because the supplies may be dangerous for them. A mask is generally worn only while performing exchanges, especially when a client has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine, not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.
77
The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?
With food
Explanation:
Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. The nurse administers phosphate binders with food for them to be effective.
78
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Increased BUN
Explanation:
The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.
79
Which of the following occurs late in chronic glomerulonephritis?
Peripheral neuropathy
Explanation:
Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.
80
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection
Explanation:
The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.
81
A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?
Hyperphosphatemia
Explanation:
Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.
82
After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do?
Discuss the complications that the client may experience if there is lack of cooperation with the care plan.
Explanation:
The nurse should discuss the care plan and its rationale with the client. Calling the health care provider to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.
83
A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first?
“My toes are stiff.”
Explanation:
Compartment syndrome is characterized by neurovascular compromise. Stiffness of the toes may be a preliminary finding that the client is having trouble with motor function.
84
Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.)
“You may cross your legs at the ankles only.”
“Place pillows between your legs when you lay on your side.”
“Avoid bending forward when sitting in a chair.”
“Use a raised toilet seat and high-seated chair.”
“It is okay to briefly flex the hip to put on your clothes.”
“Place pillows between your legs when you lay on your side.”
“Avoid bending forward when sitting in a chair.”
“Use a raised toilet seat and high-seated chair.”
The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying.
85
A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?
Elevate the affected extremity and use cold applications.
Explanation:
Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).
86
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure:
the client that he or she won't be cut
Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.
87
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?
Pulmonary embolism
Explanation:
Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
88
A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses?
maintaining adequate circulation
Explanation:
Circulation, sensation, and mobility of exposed fingers or toes must be assessed every 1 to 2 hours to ensure neurovascular status is not compromised.
89
A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse?
Assess for complications.
Explanation:
Unrelieved pain can be an indicator of a complication, such as compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the client for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.
90
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?
Weights hanging and touching the floor
Explanation:
When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.
91
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty
Explanation:
A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
92
Which objective symptom of a UTI is most common in older adults, especially those with dementia?
Change in cognitive functioning
Explanation:
The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these clients usually exhibit even more profound cognitive changes with the onset of a UTI. Incontinence, hematuria, and back pain are not the most common presenting objective symptoms.
93
Which metabolic defects are associated with stone formation?
Hyperparathyroidism
Explanation:
Metabolic defects such as hyperparathyroidism and hyperuricemia (gout) are associated with stone formation. Hypoparathyroidism, hyperthyroidism, and hypouricemia are not associated with stone formation.
94
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?
Decreased pelvic muscle tone due to multiple pregnancies
Explanation:
Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.
95
Patients with urolithiasis need to be encouraged to:
Increase their fluid intake so that they can excrete up to 4 liters every day.
Explanation:
Fluids need to be increased up to 4 L/day to increase hydrostatic pressure within the urinary tract and thereby promote passage of the stone. This volume of fluid intake also helps prevent additional stone formation.
96
The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
Coffee in the morning
Explanation:
The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
97
A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?
Low-purine diet
Explanation:
For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited.
98
The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis?
A client with urinary obstruction
Explanation:
The client with urinary obstruction is at the highest risk of developing pyelonephritis because a urinary obstruction is the most common cause of pyelonephritis in older adults. Acute glomerulonephritis usually occurs in older adults with preexisting chronic glomerulonephritis. Older clients with acute renal failure or urinary tumor are not at high risk for developing pyelonephritis.
99
A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse’s postoperative plan of care should include which action?
Maintain skin and stomal integrity.
Explanation:
The most important postoperative nursing management is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor. Determining the client’s ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.
100
Which term refers to inflammation of the renal pelvis?
Pyelonephritis
Explanation:
Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.
101
The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which item should the nurse include?
Implement a 2- to 3-hour voiding schedule
Explanation:
Immediately after the removal of the indwelling catheter, the client is placed on a voiding schedule, usually 2 to 3 hours. At the given time, the client is instructed to void. Immediate voiding is not usually encouraged.
102
The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?
Anticoagulation therapy
Explanation:
Anticoagulation therapy and early ambulation are very important for clients who have knee or hip replacement to prevent thrombus formation. The other therapy is not indicated solely for the knee or hip arthroplasty.
103
A nurse would most likely expect the need for open reduction for a client with which of the following?
Joint fracture
Explanation:
An open reduction is required when soft tissue is caught between the ends of the broken pieces of bone, the bone has a wide separation, open fractures are evident, comminuted fractures are present, and the patella or other joints are fractured. It is also done when wound debridement or internal fixation is needed.
104
Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?
Fasciotomy
Explanation:
A fasciotomy is a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure. An osteotomy is a surgical cutting of bone. An arthroplasty is a surgical repair of a joint. Arthrodesis is a surgical fusion of a joint.
105
A client with a right leg fracture is returning to the orthopedist to have the cast removed. What would the physician prescribe as further treatment?
physical therapy
Explanation:
For some time, the limb will need support. An elastic bandage may be wrapped on a leg, the client may use a cane, and an arm may be kept in a sling until progressive active exercise and physical therapy help the client regain normal strength and motion.
106
A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care?
Limit hip flexion of the client's hip when the client sits up.
Explanation:
The nurse should instruct the client to limit hip flexion to 90 degrees when sitting. The nurse should supply an elevated toilet seat so that the client can sit without having to flex the hip more than 90 degrees. The nurse should instruct the client not to cross legs to avoid dislodging or dislocating the prosthesis. The nurse should caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable.
107
A client is seen in the emergency department for an injury acquired from falling off of a bicycle and fracturing the arm. The client also has a long laceration that has been sutured in the same area. The client asks the nurse why a splint is applied and not a cast. What is the best explanation by the nurse?
“We will need to monitor the status of the laceration to be sure it does not get infected.”
Explanation:
A splint would be used when there is special skin treatment or observation that is required. The arm fracture would require the same form of immobilization that a leg fracture does. The length of time the splint can be worn is equal to that of a cast to immobilize the fracture. The cost of the splint and cast would be similar.
108
Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm?
Skin traction
Explanation:
Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period.
109
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?
Apply lotions and take warm baths or soaks.
Explanation:
The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.
110
A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan?
Assessing movement and sensation in the fingers of the right hand
Explanation:
The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn't restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the cast pores to the skin below. Unlike a plaster cast, a Fiberglass cast dries quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are found in the legs.
111
The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client’s lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse?
Call the physician to inform them of the findings.
Explanation:
The findings of the nurse indicate that the client may have a fat embolus, and the physician should be informed immediately. Administration of pain medication is not indicated at this time. The rash is not indicative of an allergic reaction. There is no indication that the rash is related to hemorrhage, and there is no need to increase the IV fluids.
112
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?
Pulmonary embolism
Explanation:
Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
113
Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse?
"CPM increases range of motion of the joint."
Explanation:
CPM increases circulation and range of motion of the knee joint.
114
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty
Explanation:
A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
115
A 68-year-old female client who had a below-the-knee amputation is to be discharged because her healing is almost complete. Which of the following would be most important for the nurse to discuss with this client?
Exploring factors related to the client’s home environment
Explanation:
Exploring factors related to the older adult client’s home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Because the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Because the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.
116
Which is not a guideline for avoiding hip dislocation after replacement surgery.
The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.
Explanation:
Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.
117
A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?
Elevate the affected extremity and use cold applications.
Explanation:
Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).
118
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans’ sign?
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.
Explanation:
The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.
119
The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse?
Drainage from wound suction device = 100 ml
Explanation:
Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.
120
A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?
Changing the client's position within prescribed limits.
Explanation:
Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas. Warm compresses aid blood circulation. The client should not exercise while on traction unless prescribed to regain strength in the affected limb.
121
A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm?
Use of isometric exercises
Explanation:
Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the client is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The client should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.
122
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?
“A splint is applied when more swelling is expected at the site of injury.”
Explanation:
Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.
123
Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery?
Apply antiembolism stockings
Explanation:
Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.
124
Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?
It promotes healing by increasing circulation and movement of the knee joint.
Explanation:
A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.
125
A client with a fractured femur is placed in skeletal traction. Which intervention will increase client independence when moving in bed?
Apply a trapeze to the bed frame.
Explanation:
To encourage movement, an assistive device called a trapeze can be suspended overhead within easy reach of the client. The trapeze helps the client move about in bed and move on and off the bedpan. The client's elbows frequently become sore, and nerve injury may occur if the client repositions by pushing on the elbows. Clients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. It is important to instruct clients not to use their heels or elbows to push themselves up in bed. The weights should not be removed to reposition the client or for any other reason.
126
A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
Right shoulder slopes downward and droops inward.
Explanation:
The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.
127
The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
Obtaining a culture
Explanation:
A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
128
Which is an inaccurate principle of traction?
The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely. The client must be in good alignment in the center of the bed. Skeletal traction is interrupted to turn and reposition the client.
Skeletal traction is interrupted to turn and reposition the client.
Explanation:
Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.
129
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is:
Risk for ineffective therapeutic regimen management
Explanation:
The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.
130
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?
osteomyelitis
Explanation:
Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.
131
A client has undergone an external fixation. Which actions would be the priority for this client?
Maintaining pin care.
Explanation:
Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client's diet and monitoring the client's urine output and blood pressure, although necessary, are not as important as maintaining pin care.
132
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?
A fasciotomy
Explanation:
A treatment option for compartment syndrome is fasciotomy.
133
A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
Assessing the extremity for neurovascular integrity
Explanation:
Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.
134
An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?
24 hours
Explanation:
Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.
135
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?
Teach the client how to prevent problems caused by immobility.
Explanation:
By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.
136
A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain?
Sharp and piercing
Explanation:
The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.
137
Which statement is accurate regarding care of a plaster cast?
The cast can be dented while it is damp.
Explanation:
The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.
138
Which would be contraindicated as a component of self-care activities for the client with a cast?
Cover the cast with plastic to insulate it
Explanation:
The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.
139
Which type of cast encloses the trunk and a lower extremity?
Hip spica
Explanation:
A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.
140
The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient?
Fat emboli syndrome
Explanation:
Fat embolism syndrome (FES) (see Chapter 43) may occur with orthopedic surgery. The nurse must be alert to any signs and symptoms that may suggest the development of FES. These may include respiratory distress; onset of delirium or any acute change in level of consciousness; and development of unusual skin rashes, especially a papular rash on the upper torso.
141
A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?
Left hip arthroplasty
Explanation:
Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.
142
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?
Cutting a cast window
Explanation:
After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client’s condition does not indicate an external fixator is required.
143
Which device is designed specifically to support and immobilize a body part in a desired position?
Splint
Explanation:
A splint may be applied to a fractured extremity initially until swelling subsides. Splints are designed to provide stability for fractures that are unstable and to immobilize and support the body part in a functional position. A brace is an externally applied device to support a body part, control movement, and prevent injury; braces are used to enhance movement while preventing injury. A sling is a bandage used to support an arm temporarily while the client ambulates; it is not designed to immobilize the body part. Traction is the use of a pulling force on a body part and thus it is not designed to immobilize; the goal of traction is to achieve or maintain alignment, decrease muscle spasms and pain, or correct or prevent deformities.
144
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?
“Metal pins will go through my skin to the bone.”
Explanation:
In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.
145
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?
Better molding to the client
Explanation:
Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.
146
The nurse is caring for a client with a cystoscopy tube draining urine from the bladder. When reviewing the client’s history prior to administering care, which is of most concern?
New diagnosis of urosepsis
Explanation:
All of the options are typical risk factors for a client with a cystoscopy tube. The most concerning risk factor is of urosepsis, which is a serious systemic infection from microorganisms in the urinary tract invading the bloodstream.
147
Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply.
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Urinary retention
Deficient knowledge: management of urinary diversion
Disturbed body image
Risk for impaired skin integrity
Chronic pain
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Deficient knowledge, disturbed body image, and risk for impaired skin integrity are expected problems for the client with a new ileal conduit. Urinary retention and chronic pain are not expected client problems.
148
An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client?
Physical and environmental conditions
Explanation:
It is essential to assess the client's physical and environmental conditions before beginning a bladder training program, because the client may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the client. It is not so essential to assess the client's history of allergy, occupation, and smoking habits before beginning a bladder training program.
149
The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
Coffee in the morning
Explanation:
The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
150
The nurse observes a client’s uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest?
A low-purine diet
Explanation:
The nurse would suggest a low-purine diet. Foods to avoid are anchovies, animal organs and sardines. The other options do not lower the uric acids levels.
151
The nurse is evaluating the effectiveness of discharge teaching for a client with an oxalate urinary stone. Which statement by the client indicates the need for further teaching by the nurse? Select all that apply.
“I will never have another urinary stone again.”
“I need to take allopurinol.”
“Tylenol is best to control my pain.”
“I need to drink eight to ten glasses of water every day.”
“I’m so glad I don’t have to make any changes in my diet.”
“I will never have another urinary stone again.”
“I need to take allopurinol.”
“Tylenol is best to control my pain.”
“I’m so glad I don’t have to make any changes in my diet.”
Correct response:
Incorrect response:
Your selection:
Explanation:
Nonsteroidal anti-inflammatory drugs are used to treat renal stone pain. Oxalate-containing foods should be avoided. Fluid intake should total 2 to 3 liters, if not contraindicated. Allopurinol (Zyloprim) is prescribed for uric acid stones. Recurrence of stones occurs in about half of individuals
152
Examination of a client’s bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
Low purine
Explanation:
A low-purine diet is used for uric acid stones; the benefits, however, are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciuria—approximately half of the clients—need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.
153
A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, “I can even feel the pain at the tip of my penis.” Which of the following would the nurse suspect?
Urinary calculi
Explanation:
Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.
154
Which nursing intervention should the nurse caring for the client with pyelonephritis implement?
Teach client to increase fluid intake up to 3 liters per day.
Explanation:
The nurse teaches the client to increase fluid intake to promote renal blood flow and flush bacteria from the urinary tract.
155
Which type of incontinence refers to the involuntary loss of urine due to extrinsic medical factors, particularly medications?
Iatrogenic
Explanation:
Iatrogenic incontinence is the involuntary loss of urine due to extrinsic medical factors, predominantly medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.
156
A client undergoes surgery to remove a malignant tumor followed by a urinary diversion procedure. Which postoperative procedure is the most important for the nurse to perform?
Maintain skin and stomal integrity.
Explanation:
The most important nursing management in postoperative procedure is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor.
157
A nurse who is taking care of a patient with a spinal cord injury documents the frequency of reflex incontinence. The nurse understands that this is most likely due to:
Loss of motor control of the detrusor muscle.
Explanation:
Spinal cord injury patients commonly experience reflex incontinence because they lack neurologically mediated motor control of the detrusor and the sensory awareness of the urge to void. These patients also experience hyperreflexia in the absence of normal sensations associated with voiding.
158
Which of the following is the most common site of a nosocomial infection?
Urinary tract
Explanation:
The urinary tract is the most common site of nosocomial infection, accounting for greater than 3% of the total number reported by hospitals each year.
159
The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of a malignant tumor of the bladder?
Hematuria
Explanation:
The most common first symptom of a malignant tumor is hematuria. Most malignant tumors are vascular; thus, abnormal bleeding can be a first sign of abnormality. The client then has symptoms of incontinence (a later sign), dysuria and frequency.
160
The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization.
Postcatheterization detrusor instability can be managed with the implementation of bladder retraining with the client.
When implementing bladder retraining for a client who experiences postcatheterization detrusor instability, the nurse first asks the client to urinate.Once the client voids, the nurse then performs the prescribed bladder scan.
Bladder retraining involves urination, not defecation. The client is instructed to drink a measured amount of fluid from 8 am to 10 pm with the implementation of bladder retraining to avoid bladder overdistention; however, the client is not instructed to drink at specific times during this process. After the client is asked to void, urinary catheterization is not performed unless the bladder scan indicates a residual greater than 300 ml. Laboratory testing is not completed as part of bladder retaining; however, the nurse should measure the volumes of urine voided and palpate the bladder at repeated intervals to assess for distention.
161
The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?
Peritonitis
Explanation:
Clinical manifestations of peritonitis include abdominal pain and distention, absence of bowel sounds, nausea and vomiting, fever, changes in vital signs.
162
Following percutaneous nephrolithotomy, the client is at greatest risk for which nursing diagnosis?
Risk for infection
Explanation:
Percutaneous nephrolithotomy is an invasive procedure for the removal of renal calculi. The client would be at risk for infection.
163
Behavioral interventions for urinary incontinence can be coordinated by a nurse. A comprehensive program that incorporates timed voiding and urinary urge inhibition is referred to as what?
Bladder retraining
Explanation:
Bladder retraining includes a timed voiding schedule and urinary urge inhibition exercises. These exercises involve delaying voiding to help the patient stay dry for a set period of time. When one time interval is reached, another is set. The time is usually increased by 10 to 15 minutes, until an acceptable voiding interval is achieved.
164
Which is the procedure of choice for men with recurrent or complicated UTIs?
Transrectal ultrasonography
Explanation:
A transrectal ultrasonography is the procedure of choice for men with recurrent or complicated UTIs.
165
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?
Acute pain
Explanation:
Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.
166
A client comes to the clinic for a follow-up visit. During the interview, the client states, “Sometimes when I have to urinate, I can’t control it and do not reach the bathroom in time.” The nurse suspects that the client is experiencing which type of incontinence?
Urge
Explanation:
Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
167
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
Perform meticulous perineal care daily with soap and water
Explanation:
Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used when inserting a urinary bladder catheter. The nurse must maintain a closed system and use the catheter’s port to obtain specimens. The catheter bag must never be placed on the client’s abdomen unless it is clamped because it may cause urine to flow back from the tubing into the bladder.
168
Which medication may be ordered to relieve discomfort associated with a urinary tract infection?
Phenazopyridine
Explanation:
Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with a UTI. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.
169
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?
Anticholinergic
Explanation:
Pharmacologic agents that can improve bladder retention, emptying, and control include anticholinergic drugs. In this classification are medications such as Detrol, Ditropan, and Urecholine. Diuretics eliminate fluid from the body but do not affect the muscles of urinary elimination. Anticonvulsant and cholinergic medications also do not directly help with control.
170
A client asks the nurse why cystitis is more common in women than in men. Which of the following body parts will the nurse include in the answer?
The urethra
Explanation:
Because the urethra is short in women, ascending infections or microorganisms carried from the vagina or rectum are common. Males have a longer urethra, causing the organisms travel farther to the bladder. Although structures of the urinary system, the other options are where the client has bacteria and microorganisms located. The ureters connect the bladder to kidney thus do not obtain bacteria, just transmit when available.
171
A client presents at the clinic with reports of urinary retention. What question should the nurse ask to obtain additional information about the client’s report?
“When did you last urinate?”
Explanation:
The nurse needs to determine the last time the client voided.
172
The nurse performs a physical examination on a client diagnosed with acute pyelonephritis to assist in determining which of the following?
Location of discomfort
Explanation:
The physical examination of a client with pyelonephritis helps the nurse determine the location of discomfort and signs of fluid retention, such as peripheral edema or shortness of breath. Observing and documenting the characteristics of the client’s urine helps the nurse detect abnormalities in the urine. Laboratory blood tests reveal elevated calcium levels, whereas radiography and ultrasonography depict structural defects in the kidneys.
173
The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do?
Take the antibiotic for 3 days as prescribed.
Explanation:
The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment. Regardless of the regimen prescribed, the patient is instructed to take all doses prescribed, even if relief of symptoms occurs promptly. Although brief pharmacologic treatment of UTIs for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTIs.
174
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
Need to urinate after engaging in sexual intercourse
Explanation:
Measures to prevent cystitis include voiding after sexual intercourse, wearing cotton underwear, urinating every 2 to 3 hours while awake, and taking showers instead of tub baths.
175
The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?
Change the wafer and pouch.
Explanation:
Whenever a leaking pouching system is noted, the nurse should change the wafer and pouch. Attempting to secure or patch the leak with tape and/or barrier paste can trap urine under the barrier or faceplate, which will compromise peristomal skin integrity. Emptying the pouch will not rectify the leaking.
176
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
“My urine will be eliminated through a stoma.”
Explanation:
An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall.
177
A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective?
Cipro
Explanation:
Ciprofloxacin (Cipro) is a fluoroquinolone used to treat UTIs. Co-trimoxazole (Bactrim, Septra) is a trimethoprim-sulfamethoxazole combination medication. Nitrofurantoin (Macrodantin, Furadantin) is an anti-infective urinary tract medication.
178
A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms?
Pyridium
Explanation:
The urinary analgesic agent phenazopyridine (Pyridium) is used specifically for relief of burning, pain, and other symptoms associated with UTI.
179
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
Kidney
Explanation:
The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.
180
A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal?
Relieve the pain.
Explanation:
The immediate objective is to relieve pain, which can be incapacitating depending on the location of the stone.
181
A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following?
Diabetes mellitus
Explanation:
Increased urinary glucose levels create an infection-prone environment in the urinary tract.
182
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
Encouraging intake of at least 2 L of fluid daily
Explanation:
Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
183
What clinical manifestation would the nurse expect to find in a client who has had osteoporosis for several years?
Decreased height
Explanation:
Clients with osteoporosis become shorter over time.
184
Which of the following is the most common and most fatal primary malignant bone tumor?
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Osteogenic sarcoma (osteosarcoma)
Explanation:
Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor. Benign primary neoplasms of the musculoskeletal system include osteochondroma, enchondroma, and rhabdomyoma.
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185
A nurse notices a client lying on the floor at the bottom of the stairs. The client is alert and oriented and denies pain other than in the arm, which is swollen and appears deformed. After calling for help, what should the nurse do?
Immobilize the client's arm.
Explanation:
Signs of a fracture in an extremity include pain, deformity, swelling, discoloration, and loss of function. When a nurse suspects a fracture, the extremity should be immobilized before moving the body part. It isn't appropriate for the nurse to move the client into a sitting position without further assessment. The client shouldn't walk to the nurses' station; the client should wait for help to arrive.
186
Morton neuroma is exhibited by which clinical manifestation?
Swelling of the third (lateral) branch of the median plantar nerve
Explanation:
Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.
187
A nurse is teaching a client about preventing osteoporosis. Which teaching point is correct?
The recommended daily allowance of calcium may be found in a wide variety of foods.
Explanation:
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.
188
The nurse is preparing a client for a surgical procedure that will allow visualization of the extent of joint damage of the knee for a client with rheumatoid arthritis and also obtain a sample of synovial fluid. What procedure will the nurse prepare the client for?
Arthroscopy
Explanation:
Arthroscopic examination may be carried out to visualize the extent of joint damage as well as to obtain a sample of synovial fluid. An open reduction would be used for the treatment of a fracture. Needle aspiration will not allow visualization of the joint damage but will allow obtaining the sample of synovial fluid. Arthroplasty is the restructure of the joint surface after diagnosis is made.
189
A nurse is performing foot care for a client with chronic osteomyelitis and the client asks the nurse about the next treatment. What is the specific treatment for a client with chronic osteomyelitis?
Surgical removal of the sequestrum
Explanation:
A sequestrectomy, removal of enough involucrum to enable the surgeon to remove the sequestrum, is performed on clients with chronic osteomyelitis. In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer (saucerization). All dead, infected bone and cartilage must be removed before permanent healing can occur. Aggressive physical therapy is not recommended until healing has occurred. Draining the infection is not sufficient to heal chronic osteomyelitis. Continued wound care is not sufficient to heal the wound.
190
A client with a musculoskeletal injury is instructed to alter the diet. The objective of altering the diet is to facilitate the absorption of calcium from food and supplements. Considering the food intake objective, which food item should the nurse encourage the client to include in the diet?
Vitamin D–fortified milk
Explanation:
The nurse should advise the client to include dietary sources of vitamin D, such as fatty fish, vitamin D–fortified milk, and cereals. These foods protect against bone loss and decrease the risk of fracture by facilitating the absorption of calcium from food and supplements. Red meat, bananas, and green vegetables do not facilitate calcium absorption from food and supplements.
191
Which condition is a metabolic bone disease characterized by inadequate mineralization of bone?
Osteomalacia
Explanation:
Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Osteoporosis is characterized by reduction of total bone mass and a change in bone structure that increases susceptibility to fracture. Osteomyelitis is an infection of bone that comes from extension of soft-tissue infection, direct bone contamination, or hematogenous spread. Osteoarthritis (OA), also known as degenerative joint disease, is the most common and frequently disabling of the joint disorders. OA affects the articular cartilage, subchondral bone, and synovium.
192
Which is not a risk factor for osteoporosis?
being male
Explanation:
Being male is not considered a risk factor. Some of the risk factors for osteoporosis are being a small-framed, thin White or Asian woman; being postmenopausal; family history; inactivity; chronic low calcium intake; and excessive caffeine or tobacco use.
193
The nurse notes that the client’s left great toe deviates laterally. This finding would be recognized as
Hallux valgus
Explanation:
Hallux valgus is commonly referred to as a bunion. Hammertoes are usually pulled upward. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. The client with flatfoot demonstrates a diminished longitudinal arch of the foot.
194
The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response?
Decrease in estrogen
Explanation:
Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.
195
A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?
Temporomandibular disorder
Explanation:
The disorder can be confused with trigeminal neuralgia and migraine headaches. The client experiences clicking of the jaw when moving the joint, or the jaw can lock, which interferes with opening the mouth. Loose teeth will not cause a clicking of the jaw. The client does not have a dislocated jaw.
196
A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?
L4, L5, and S1
Explanation:
The lower lumbar disks, L4–L5 and L5–S1, are subject to the greatest mechanical stress and the greatest degenerative changes. Disk protrusion (herniated nucleus pulposus) or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve.
197
A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include?
"Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."
Explanation:
Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints.
198
Which term refers to a disease of a nerve root?
Radiculopathy
Explanation:
When the client reports radiating pain down the leg, the client is describing radiculopathy. Involucrum refers to new bone growth around the sequestrum. Sequestrum refers to dead bone in an abscess cavity. Contracture refers to abnormal shortening of muscle or fibrosis of joint structures.
199
A healthcare provider asks a nurse to test a client for Tinel's sign to diagnose carpal tunnel syndrome. What should the nurse do to perform this assessment?
Have the client hold the palm of the hand up while the nurse percusses over the median nerve.
Explanation:
If tingling, numbness, or pain is felt when the median nerve is percussed, then Tinel's sign is considered positive. To test for Tinel's sign have the client hold the palm of the hand up while the nurse percusses over the median nerve. The client making a fist and pushing will test strength resistance. The client stretching fingers around a ball will not test for Tinel's sign. Having the client pronate the hand and palpating the radial nerve is not Tinel's sign used for carpal tunnel syndrome diagnosis.
200
A client with carpal tunnel syndrome has had limited improvement with the use of a wrist splint. The nurse knows that which procedure will show the greatest improvement in treatment for this client?
Open nerve release
Explanation:
Evidence-based treatment of acute carpal tunnel syndrome includes the application of splints to prevent hyperextension and prolonged flexion of the wrist. Should this treatment fail, open nerve release is a common surgical management option. A variety of treatments may be tried by the client, however, they may fail to improve the condition. These treatments include laser therapy, ultrasound therapy, and the injection of substances such as lidocaine. Though these can be used, surgery to release nerves is the best option.
201
Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes?
Lower lumbar
Explanation:
The lower lumbar disks, L4 to L5 and L5 to S1, are subject to the greatest mechanical stress and greatest degenerative changes.
202
A client diagnosed with carpal tunnel syndrome (CTS) asks the nurse about numbness in the fingers and pain in the wrist. What is the best response by the nurse?
“CTS is a neuropathy that is characterized by compression of the median nerve at the wrist.”
Explanation:
Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tissue mass.
203
Which organism is responsible for impetigo?
Staphylococcus aureus
Explanation:
S. aureus and Streptococcus pyogenes are the organisms responsible for impetigo. H. capsulatum is responsible for histoplasmosis. B. anthracis is responsible for anthrax. C. difficile is responsible for some diarrheal diseases.
204
The school health nurse is conducting a teaching session for parents to provide information about the human papillomavirus (HPV) vaccination. What prevention information should the nurse include in the session?
The effect of the vaccination is optimized if it is administered before the child becomes sexually active.
Explanation:
The nurse should advise the parents that the vaccination should ideally be administered before the onset of sexual activity, to prevent genital warts. The vaccination is available and effective when administered to both men and women. The HPV vaccination does not preclude women from having regular cervical cancer screening in the future. A Pap smear prior to the administration of the vaccination is not required, particularly for those woman who are not yet sexually active.
205
The nurse is providing care to a client who has been diagnosed with gonorrhea. The nurse also prepares the client for treatment of which of the following?
Chlamydia
Explanation:
Co-infection with chlamydia often occurs in clients infected with gonorrhea. Therefore, the nurse would expect the client to receive treatment for both of these diseases. Human immunodeficiency virus, syphilis, and herpes simplex are not commonly associated with gonorrhea.
206
A pregnant patient asks the nurse if it is all right for her take the varicella immunization for entrance into nursing school. What is the best response by the nurse?
“It is not recommended that pregnant women take the live virus. You should wait until after your child is born.”
Explanation:
Some live vaccines (e.g., varicella, MMR [against measles, mumps, and rubella], yellow fever) are contraindicated for people who are severely immunosuppressed or pregnant.
207
Patients who have had pelvic inflammatory disease (PID) are prone to which of the following complications?
Ectopic pregnancy
Explanation:
All patients who have had PID need to be informed of the signs and symptoms of ectopic pregnancy because they are prone to this complication. Other complications include bacteremia with septic shock and thrombophlebitis with possible embolization. Patients who have PID are not prone to inguinal lymphadenopathy
208
A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea?
Burning on urination
Explanation:
Burning on urination may be a symptom of gonorrhea or urinary tract infection. A dry, hacking cough is a sign of a respiratory infection, not gonorrhea. A diffuse rash may indicate secondary stage syphilis. A painless chancre is the hallmark of primary syphilis. It appears wherever the organisms enter the body, such as on the genitalia, anus, or lips.
209
You are a school nurse teaching a health class about the chain of infection in the transmission of sexually transmitted diseases (STDs). A student asks you which part of the chain of infection can be missing when transmission occurs. What would be your best answer?
“All parts of the chain of infection have to be present for the disease to be passed to another human.”
Explanation:
All components in the chain of infection must be present for an infectious disease to be transmitted from one human or animal to a susceptible host. This makes options A, B, and C incorrect.
210
The nurse is caring for a client diagnoses with severe acute respiratory syndrome (SARS). A family member asks what causes SARS. Which response by the nurse is accurate?
Coronavirus
Explanation:
SARS is a severe acute viral respiratory illness caused by the coronavirus, typically the symptoms include fever, coughing, difficulty breathing, and pneumonia.
211
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
“Make sure your family has all their childhood immunizations.”
Explanation:
To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization of children protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.
212
Which of the following sexually transmitted infections (STIs) could be transmitted perinatally?
Herpes simplex
Explanation:
Herpes simplex and syphilis can be transmitted perinatally and sexually. Chlamydia, gonorrhea, and trichomoniasis are transmitted sexually.
213
The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and
mode of entry into the host.
Explanation:
The six elements necessary for infection are a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and a mode of entry into, not a mode of exit from, the host.
214
The parent of a child diagnosed with chickenpox asks when the child can go to play group again. What is the best response by the nurse?
“When the vesicles and pustules have crusted.”
Explanation:
When the lesions have crusted, the client is no longer contagious to others. The child remains contagious when the rash is present, and if the fever occurs as the rash is progressing. The child is still contagious when the rash is changing into vesicles and pustules.
215
After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?
Genital herpes
Explanation:
Besides AIDS, the five most common STIs are chlamydia, gonorrhea, syphilis, genital herpes, and genital warts. Of these, chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes recurs.
216
Which of the following is the medication of choice for early syphilis?
Penicillin G benzathine
Explanation:
A single dose of penicillin G benzathine intramuscular injection is the medication of choice for early syphilis or early latent syphilis of less than 1 year’s duration. Patients who are allergic to penicillin are usually treated with doxycycline or tetracycline. Rocephin is not the medication of choice for syphilis.
217
The nurse is completing a community education via a pamphlet on sexually transmitted diseases. Which key point is most important for the nurse to emphasize?
Many people are asymptomatic and show no symptoms contributing to the spread of the disease.
Explanation:
The nurse is most correct to emphasize information regarding prevention of sexually transmitted diseases. The information that many people are asymptomatic and show no symptoms is an important point to stress. Common age-groups are an interesting fact. Repercussions of the disease are also important to highlight; however, prevention is most important.
218
The nurse teaches the parent of a child with chickenpox that the child is no longer contagious to others when
the vesicles and pustules have crusted.
Explanation:
When the lesions have crusted, the client is no longer contagious to others. The child remains contagious when the rash is present, if fever occurs as the rash is progressing, and when the rash is changing into vesicles and pustules.
219
Which statement reflects what is known about the Ebola virus?
The diagnosis should be considered in a client who has a febrile, hemorrhagic illness after traveling to Asia or Africa.
Explanation:
The diagnosis should be considered in a client who has a febrile, hemorrhagic illness after traveling to Asia or Africa, or who has handled animals or animal carcasses from those parts of the world. Antibiotic therapy, such as penicillin, would not be effective for the treatment of viruses. Treatment must be largely supportive maintenance of the circulatory and respiratory systems. The infected client likely would need ventilator and dialysis support through the acute phases of illness. The viruses are usually spread by exposure to blood or other body fluid, insect bite, and mucous membrane exposure. Symptoms include fever, rash, and encephalitis, which progress rapidly to profound hemorrhage, organ destruction, and shock.
220
The nurse is completing the admission assessment on a client with renal failure. The client states, “I was diagnosed with impetigo yesterday.” Which is the appropriate nursing intervention?
Initiate contact isolation protocol.
Explanation:
Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The client would not be taking an antiviral medication for impetigo, would not need a negative-pressure room, and would not wear a mask when outside the room.
221
A 36-year-old client is in the clinic for an annual physical. The client asks the nurse, "Should I get a flu shot?" Which is the best response by the nurse?
“The flu shot is recommended for all people over 6 months of age.”
Explanation:
The influenza vaccine is recommended for all people over 6 months of age; therefore the client is in the recommended age range. Ascertaining whether the client has any chronic illnesses is important, but it does not change the recommendation by the Centers for Disease Control and Prevention. No recommendation suggests that the immunization be given only if the client works around children or the elderly.
222
A nurse is caring for a male client with gonorrhea who's receiving ceftriaxone (Rocephin) and doxycycline (Vibramycin). The client asks the nurse why he's receiving two antibiotics. How should the nurse respond?
"Many people infected with gonorrhea are infected with chlamydia as well."
Explanation:
Treatment for gonorrhea includes the antibiotic ceftriaxone. Because many people with gonorrhea have a coexisting chlamydial infection, doxycycline or azithromycin (Zithromax) is also ordered. There has been an increase in the number of resistant strains of gonorrhea, but that isn't the reason for this dual therapy. This combination of antibiotics doesn't reduce the risk of reinfection or provide a faster cure.
223
You work on a long-term care unit. In the last two weeks more than half the clients on your unit have been diagnosed with gastroenteritis. What is the most likely reason?
The infection is being transmitted by healthcare personnel.
Explanation:
Healthcare personnel are in frequent and direct contact with many clients who harbor various microorganisms; the risk for transmitting pathogenic microorganisms between clients is high.
224
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?
Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.
Explanation:
Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.
225
The nurse is working in the labor and delivery suite when a client with active herpes simplex virus type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care will the nurse prepare for?
Prepare for a cesarean section.
Explanation:
The nurse is most accurate to prepare for a cesarean section because the mother has an active lesion and does not want to transmit the virus to the newborn. Antibiotic therapy, at this time, does not prevent the transmission of the infection. A full assessment is always completed on the newborn and is not an adjustment in the plan of care. Antibacterial ointment is not placed on the mother’s lesions.
226
The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection?
Gonorrhea
Explanation:
When symptoms of gonorrhea are present in male clients, the symptoms may include burning during urination and penile discharge. Clients with Neisseria gonorrhoeae infection also may report painful swollen testicles. The latter symptoms distinguishes this infection from the infections in the alternate options. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. With herpes genitalis primary infection may begin with macules (small flat spots on skin) and papules (small circumscribed elevations) and progress to vesicles (small, serous-filled elevated spots) and ulcers. The vesicular state often appears as a blister, which later coalesces, ulcerates, and encrusts. Influenza-like symptoms may occur 3 or 4 days after the lesions appear, often with inguinal lymphadenopathy (enlarged lymph nodes in the groin). Men with trichomoniasis may notice itching or irritation inside the penis, burning after urination or ejaculation, discharge from the penis.
227
Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?
Time between exposure and onset of symptoms
Explanation:
The incubation period is time between contact or exposure and the development of the first signs and symptoms. The presence of microorganisms without the host interacting with them is called colonization. The state in which the host displays a decrease in wellness characterizes an infectious disease. The process of the host shedding the microorganisms to another reflects the mode of exit.
228
A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
thirst or irritability.
Explanation:
Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.
229
Which term refers to a state of microorganisms being present within a host without causing host interference or interaction?
Colonization
Explanation:
Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is one that does not possess immunity to a particular pathogen. An immune host is one that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism.
230
The nurse is teaching a health class in the local public health center. What instructions should the nurse provide as the single most important measure to prevent the spread of infection?
Thorough handwashing
Explanation:
Hand hygiene remains the single most important measure to prevent the spread of infection. It reduces the number of transient and resident microorganisms. Sufficient food intake helps restore biologic defense mechanisms but does not prevent spread of infections. Although minimal social contact and regular immunizations may help prevent the spread of infection, especially community-acquired infections, these are not practical measures.
231
A nurse would anticipate instituting contact precautions for a client with which of the following?
Clostridium difficile infection
Explanation:
Contact precautions would be appropriate for a client with an infection due to Clostridium difficile. Airborne precautions are appropriate for clients with measles or varicella. Droplet precautions are appropriate for clients with mumps.
232
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find:
tachycardia.
Explanation:
With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.
233
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?
Measles
Explanation:
Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.
234
When a hospitalized client requires contact precautions, which responses is necessary?
The client should be placed in a private room when possible.
Explanation:
When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.
235
A nurse is having a yearly employee tuberculin skin test. Which skin test results would indicate a positive result?
An induration of 12mm
Explanation:
The size of the induration, not including the surrounding area of erythema, is measured in millimeters. The measurement determines whether the reaction is significant. For example, a tuberculin skin test is test is considered positive if the induration is 10 mm or greater in persons with no known risk factors for TB; smaller measurements are significant in certain risk groups, such as immunocompromised clients. The other answers are not indicative of positive results.
236
```
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply.
Temperature of 102F
Heart rate of 120 beats/minute
Respiratory rate of 24 breaths/minute
PaCO2 of 42 mm Hg
Blood pressure of 120/80 mm Hg
```
Two or more of the following characterize sepsis: temperature greater than 100.4F (38C), heart rate greater than 90 beats/minute, respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mm Hg, WBC count greater than 12,000 cells/mm3, or 10% immature (band) forms. Blood pressure is not an indicator of sepsis, and a PaCO2 of 42 mm Hg is not an indicator.
237
A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute?
Contact
Explanation:
A client with scabies requires contact isolation because the disease is highly transmissible through close or direct contact. Scabies is not transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with scabies. Enteric isolation is inappropriate because scabies is not transmitted through direct or indirect contact with feces.
238
The usual incubation period (from infection to first symptom) for hepatitis B is
45 to 160 days.
Explanation:
Hepatitis B is responsible for more than 200 deaths of healthcare workers annually. The incubation period for hepatitis B is 45 to 160 days. The incubation period for hepatitis A is 15 to 50 days; for gonorrhea, 2 to 7 days. The incubation for the Sin Nombre virus is unclear.
239
The nurse is trying to determine if a patient admitted to the hospital the previous day has a bacterial wound infection. What laboratory study should the nurse review to obtain this information?
Microbiology report
Explanation:
The primary source of information about most bacterial infections is the microbiology laboratory report, which should be viewed as a tool to be used along with clinical indicators to determine if a patient is colonized, infected, or diseased.
240
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis
Explanation:
Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.
241
Which stage or period of syphilis occurs when the infected person has no signs or symptoms of syphilis?
Latency
Explanation:
Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. A period of latency occurs when the infected person has no signs or symptoms of syphilis. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. Tertiary syphilis presents as a slowly progressive inflammatory disease with the potential to affect multiple organs.
242
The nurse is providing education to a client who has been diagnosed with chlamydia. The client will begin treatment with azithromycin today. Which teaching point should the nurse reinforce with this client?
"Abstain from any sexual activity for 1 week after the antibiotic is complete."
Explanation:
Client counseling includes abstinence for 1 week after treatment, in addition to the completion of the partner’s treatment. Although handwashing is an important aspect of preventing the spread of infection, the nurse must emphasize prevention of chlamydia through the normal route of transmission of this infection, which is sexually. Coinfection with chlamydia often occurs in clients infected with gonorrhea. Chlamydia and gonorrhea are caused by bacteria that are transmitted during sexual relations. Both chlamydia and gonorrhea infections frequently do not cause symptoms in women and thus are often referred to as “silent” related to clinical presentation. It is important to retest women 3 months’ posttreatment, due to the possibility of reinfection.
243
After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following?
Vigorously scrubbing between the fingers
Explanation:
Effective handwashing requires at least 15 seconds of vigorous scrubbing with special attention to the area around nail beds and between fingers, where there is high bacterial load. Hands should be thoroughly rinsed after washing and then dried. Artificial fingernails should not be worn.
244
Flu and cold season offers excellent examples of physiologic reflexes to ward off illness. One problem is that an effective mechanical defense for one person can complete a link in the chain of infection for someone else. To which link is the above referring?
means of transmission
Explanation:
As a person sneezes or coughs, if he or she does not cover his or her mouth and nose, the airborne microbes can be spread to others, finding a susceptible host. Covering up when coughing or sneezing is vital protection against infection. The reservoir refers to the environment in which the infectious agent can survive and reproduce. Portal of entry refers to the route by which the infectious agent escapes from the environment in which it lives and reproduces. Infectious agent refers to the agent that has the power to produce disease.
245
The nurse is presenting a community lecture about STIs, and emphasizes that some STIs are easily cured with early and adequate treatment. Which is not among these easily treated diseases?
genital herpes
Explanation:
Chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes is not.
246
Symptoms of pelvic infection usually begin with which of the following?
Pain
Explanation:
Symptoms of pelvic infection usually begin with vaginal discharge, dyspareunia (painful sexual intercourse), lower abdominal pelvic pain, and tenderness that occur after menses. Other symptoms include fever, general malaise, anorexia, nausea, headache, and possibly vomiting.
247
The nurse has received several laboratory studies back at the clinic. Which of these results should be reported to the local health department?
Positive gonorrhea
Explanation:
Gonorrhea and chlamydia are reportable communicable diseases. In any healthcare facility, a mechanism should be in place to ensure that all diagnosed patients are reported to the local public health department to ensure follow-up of the patient. The public health department also is responsible for interviewing the patient to identify sexual contacts so that contact notification and screening can be initiated.
248
The nurse educator, who is teaching a class on sexually transmitted infections, recognizes that teaching has been effective when students indicate which statement is true about the difference between colonization and infection?
"Colonization becomes infection when the host and organism interact."
Explanation:
The term colonization is used to describe microorganisms present without host interference or interaction. Infection indicates a host interaction with an organism. Organisms reported in microbiology test results often reflect colonization rather than infection. Clinical evidence of redness, heat, and pain and laboratory evidence of white blood cells on the wound specimen smear suggest infection. In this situation, the host identifies the staphylococci as foreign. Infection is recognized by the host reaction (manifested by signs and symptoms) and by laboratory-based evidence of white blood cell reaction and microbiologic organism identification. Colonization does not require treatment with antibiotics because the host has not experienced physiological consequences from the presence of colonization. Infection may require treatment with antibiotics due to the severity of the host reaction.
249
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?
An isolation room three doors from the nurses' station
Explanation:
A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
250
```
During flu season, a nurse is teaching clients about the chain of infection. What components are considered “links” in this chain? Select all that apply.
virulence
infectious agent
portal of entry
susceptible host
fomites
```
The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.
251
What term refers to a flexion deformity caused by a slowly progressive contracture of the palmar fascia?
Dupuytren contracture
Explanation:
Dupuytren disease results in a slowly progressive contracture of the palmar fascia, called Dupuytren contracture. A callus is a discretely thickened area of skin that has been exposed to persistent pressure or friction. A hammertoe is a flexion deformity of the interphalangeal joint, which may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally.
252
For each assessment finding, click to specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis.
Risk factors for osteoporosis include older age (for women, the risk increases after age 50), Asian heritage, being a postmenopausal woman, and long-term corticosteroid use (such as fluticasone for the treatment of asthma). A small frame, not a large frame, increases the risk for osteoporosis. Being a nonsmoker does not increase the risk for osteoporosis. An alcohol intake of 3 or more drinks/day is a risk factor for osteoporosis; an intake of 3 alcoholic beverages/week does not increase the risk. A sedentary lifestyle also increases the risk for osteoporosis; however, walking 2 miles, 3 days/week is not considered sedentary.
253
The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis? Select all that apply.
Trauma, such as penetrating wounds or compound fractures
Vascular insufficiency in clients with diabetes or peripheral vascular disease
Surgical contamination, such as pin sites of skeletal traction
Progressive osteoporosis
The following are all causes of osteomyelitis: trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.
254
A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?
Initiating weight-bearing exercise routines
Explanation:
Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg.
255
A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching?
“You will receive IV antibiotics for 3 to 6 weeks.”
Explanation:
Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks. Continuous passive range of motion is used for clients with osteoarthritis. Weight-bearing exercises are used with clients who have osteoporosis. Limiting protein and calcium is not part of the plan of care for clients with osteomyelitis.
256
What food can the nurse suggest to the client at risk for osteoporosis?
Broccoli
Explanation:
Calcium is important for the prevention of osteoporosis. Broccoli is high in calcium.
257
The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given?
Alendronate
Explanation:
Alendronate is a bisphosphonate medication. Raloxifene is a selective estrogen receptor modulator. Teriparatide is an anabolic agent, and denosumab is a monoclonal antibody agent.
258
Which assessment findings would the nurse expect to find in the client with osteomyelitis?
Osteomyelitis is characterized by elevated white blood cell count and erythrocyte sedimentation rate.
259
A client has Paget’s disease. An appropriate nursing diagnosis for this client is:
Risk for falls
Explanation:
The client with Paget’s disease is at risk for falls secondary to pathological fractures and impaired gait/mobility.
260
A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing?
Surgical debridement
Explanation:
In chronic osteomyelitis, surgical debridement is used when the wound fails to respond to antibiotic therapy. Wound packing, vitamin supplements, and wound irrigation are not the standard of care when treating chronic osteomyelitis.
261
During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height."
Explanation:
The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.
262
The nurse is assisting a client with removing shoes prior to an examination and observes that the client has a flexion deformity of several toes on both feet of the proximal interphalangeal (PIP) joints. What can the nurse encourage the client to do?
Wear properly fitting shoes.
Explanation:
Hammer toe is a flexion deformity of the PIP joint and may involve several toes and may result from wearing poorly fitting shoes. They will not straighten by binding the toes or doing active range of motion exercises. Surgery is an option but should be discussed with an orthopedic surgeon or podiatrist.
263
A client with diabetes punctured the foot with a sharp object. Within a week, the client developed osteomyelitis of the foot. The client was admitted for IV antibiotic therapy. How long does the nurse anticipate the client will receive IV antibiotics?
At least 4 weeks
Explanation:
Identification of the causative organism to initiate appropriate and ongoing antibiotic therapy for infection control. IV antibiotic therapy is administered for at least 4 weeks, followed by another 2 weeks (or more) of IV antibiotics or oral antibiotics.
264
The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided?
“I will avoid prolonged sitting or walking.”
Explanation:
The nurse encourages the patient to alternate lying, sitting, and walking activities frequently, and advises the patient to avoid sitting, standing, or walking for long periods.
265
A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following?
Staphylococcus aureus
Explanation:
Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli.
266
Which group is at the greatest risk for osteoporosis?
European American women
Explanation:
Small-framed, nonobese European American women are at greatest risk for osteoporosis. Asian American women of slight build are at risk for low peak bone mineral density. African American women, who have a greater bone mass than European American women and Asian American Women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction.
267
A nurse is caring for a client following foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan?
Perform neuromuscular assessment every hour.
Explanation:
The priority nursing intervention is to perform a neuromuscular assessment every hour. Early detection of neurological and perfusion problems is important to prevent complications from the surgery. The surgical dressing does not need to be examined hourly. Administering pain medication is important, but assessing the foot color and temperature are most important. Vital sign monitoring is important, but not a priority after foot surgery.
268
Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD?
Calcitonin (Miacalcin)
Explanation:
Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD. Raloxifene reduces the risk of osteoporosis by preserving BMD without estrogenic effects on the uterus. Teriparatide has been recently approved by the FDA for the treatment of osteoporosis.
269
A patient had hand surgery to correct a Dupuytren’s contracture. What nursing intervention is a priority postoperatively?
Performing hourly neurovascular assessments for the first 24 hours
Explanation:
Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.
270
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
Serum potassium level of 2.6 mEq/L
Explanation:
Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.
271
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a bone marrow transplant?
Monitor the client closely to prevent infection.
Explanation:
Until transplanted bone marrow begins to produce blood cells, these clients have no physiologic means to fight infection, which makes them very prone to infection. They are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent infection. Monitoring client's toilet patterns, physical condition, and heart rate does not prevent the possibility of the client getting an infection.
272
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
"You will need to practice birth control measures."
Explanation:
Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known.
273
A decrease in circulating white blood cells is
leukopenia.
Explanation:
A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.
274
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
Explanation:
Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
275
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?
Place the client in a private room.
Explanation:
Safety precautions are used for the client with a radioactive implant. They include assigning the client to a private room, seeing that visitors maintain a 6-foot distance from the radiation source, prohibiting visits by children, and preventing exposure to those who may be or are pregnant. Staff needs to wear dosimeters. Family may visit for up to 30 minutes per day.
276
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action?
Ham and bacon
Explanation:
Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate and nitrite-containing foods, and red and processed meats. Nitrates are added to cured meats, such as ham and bacon.
277
A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend?
Oranges
Explanation:
A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. Hot dogs and smoked and cured foods are high in nitrates, which may be linked to esophageal and gastric cancers. Steak is a high-fat food that may increase the risk of breast, colon, and prostate cancers.
278
Which should a nurse thoroughly evaluate before a bone marrow transplant (BMT) procedure?
Blood studies
Explanation:
Before the BMT procedure, the nurse thoroughly evaluates the client's physical condition; organ function; nutritional status; complete blood studies, including assessment for past exposure to antigens such as HIV, hepatitis, or cytomegalovirus; and psychosocial status. Before a BMT procedure, the nurse need not evaluate the client's family, drug, or allergy history.
279
In which phase of the cell cycle does cell division occur?
Mitosis
Explanation:
Cell division occurs in mitosis. RNA and protein synthesis occurs in the G1 phase. DNA synthesis occurs during the S phase. DNA synthesis is complete, and the mitotic spindle forms in the G2 phase.
280
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel
Explanation:
A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. The WBC count and temperature are within normal limits. Eating 75% of meals is normal and doesn't increase the client's risk for infection. A client who is malnourished is at a greater risk for infection.
281
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stops the chemotherapeutic infusion
Explanation:
The client may be experiencing a type I hypersensitivity reaction, which may progress to systemic anaphylaxis. The most immediate action of the nurse is to discontinue the medication followed by initiating emergency protocols.
282
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?
Wear disposable gloves and protective clothing.
Explanation:
A nurse must wear disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. The nurse shouldn't recap or break needles. The nurse should use a sterile gauze pad when priming I.V. tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, I.V. tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.
283
A client is receiving external radiation to the left thorax to treat lung cancer. Which intervention should be part of this client's care plan?
Avoiding using soap on the irradiated areas
Explanation:
Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.
284
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior?
Progression
Explanation:
Progression is the third step of carcinogenesis, in which cells show a propensity to invade adjacent tissues and metastasize. During promotion, repeated exposure to promoting agents causes the expression of abnormal genetic information, even after long latency periods. During initiation, initiators such as chemicals, physical factors, and biologic agents escape normal enzymatic mechanisms and alter the genetic structure of cellular DNA. No stage of cellular carcinogenesis is termed prolongation.
285
A client diagnosed with cancer makes the following statement to the nurse: “I guess I will tell my health care provider to forego the chemotherapy. I do not want to be throwing up all the time. I would rather die.” Which of the following facts supports the use of chemotherapy for this client?
Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects.
Explanation:
Chemotherapy is not one drug for all clients. The therapy can be specifically designed to optimize effects while limiting adverse effects with supplemental anti emetics to control the nausea and vomiting. It is true that nausea and vomiting are most prevalent in the first 24 hours after each chemotherapy treatment but this does not eliminate the fears expressed by this client. No one can state the worth of any treatment, and a cure is never promised. Clinical trials open up new options for treatment, but the process is lengthy and is not a certainty for a client in need of immediate treatment.
286
You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear?
Fatigue
Explanation:
Clients with cancer experience fatigue, which is a side effect of cancer treatments that rest fails to relieve. The nurse must assess the client for other stressors that contribute to fatigue such as pain, nausea, fear, and lack of adequate support. The nurse works with other healthcare team members to treat the client's fatigue. The above indications do not contribute to infections, ulcerations, or high cholesterol levels.
287
What disadvantages of chemotherapy should the patient be informed about prior to starting the regimen?
It targets normal body cells as well as cancer cells.
Explanation:
Chemotherapy agents affect both normal and malignant cells; therefore, their effects are often widespread, affecting many body systems.
288
A client is receiving external radiation to the left thorax to treat lung cancer. Which intervention should be part of this client's care plan?
Avoiding using soap on the irradiated areas
Explanation:
Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.
289
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue?
Excisional biopsy
Explanation:
Excisional biopsy is most frequently used for small, easily accessible tumors of the skin, breast, and upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. Needle biopsy is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis.
290
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently.
Explanation:
Inspecting the skin frequently will allow early identification and intervention of skin problems associated with external radiation therapy. The external markings should not be removed, but clients may shower and lightly wash over the skin. Time, distance, and shielding are key in the management of sealed, internal radiation therapy and not external beam radiation. The use of disposable utensils and care items would be important when caring for clients following systemic, unsealed, internal radiation therapy.
291
Which type of surgery is used in an attempt to relieve complications of cancer?
Palliative
Explanation:
Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.
292
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate?
Adjuvant therapy is likely.
Explanation:
T3 indicates a large tumor size, with N1 indicating regional lymph node involvement so treatment is needed. A T3 tumor must have its size reduced with adjuncts like chemotherapy and radiation. Although M0 suggest no metastasis, following with adjuvant (chemotherapy or radiation therapy) treatment is indicated to prevent the spread of cancer outside the lymph to other organs. The tumor stage IV wound be indicative of palliative care. A repeated biopsy is not needed until after treatment is completed.
293
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior?
Progression
Explanation:
Progression is the third step of carcinogenesis, in which cells show a propensity to invade adjacent tissues and metastasize. During promotion, repeated exposure to promoting agents causes the expression of abnormal genetic information, even after long latency periods. During initiation, initiators such as chemicals, physical factors, and biologic agents escape normal enzymatic mechanisms and alter the genetic structure of cellular DNA. No stage of cellular carcinogenesis is termed prolongation.
294
A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would most likely decrease the pain associated with stomatitis?
Provide a solution of viscous lidocaine for use as a mouth rinse.
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection, but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.
295
The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions?
Extravasation of vesicant chemotherapeutic agents can lead to erythema, sloughing, and necrosis of surrounding tissue, muscle, and tendons. To reduce the likelihood and severity of symptoms due to extravasation of a vesicant, antidotes matched to the vesicant are administered. Nurses caring for a client who experienced extravasation of a vesicant should assess for sloughing tissue, tissue necrosis, erythema, and effectiveness of the antidote.
296
A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include?
Use a soft toothbrush and allow it to air dry before storing.
Explanation:
The nurse advises the client undergoing radiation therapy to use a soft toothbrush to avoid gum lacerations and allow the toothbrush to air dry before storing. Gargling after each meal, flossing before going to bed, and treating cavities immediately are general oral hygiene instructions.
297
The oncology nurse is giving chemotherapy to a client in a short stay area. The client confides that they are very depressed. The nurse recognizes depression as which of the following?
A normal reaction to the diagnosis of cancer.
Explanation:
Clients have many reactions, ranging from anxiety, fear, and depression to feelings of guilt related to viewing cancer as a punishment for past actions or failure to practice a healthy lifestyle. They also may express anger related to the diagnosis and their inability to be in control. While depression is understandable, it also needs to be acknowledged and treated if necessary. Depression is not a side effect of the neoplastic drugs nor is it an aberrant psychologic reaction to the chemotherapy.
298
The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician’s recommendation?
To prevent the formation of new cancer cells
Explanation:
Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present; also, it can be used prophylactically to prevent spread. Biopsy is used to analyze lymph nodes or to destroy the surrounding tissues around the tumor.
299
According to the tumor-node-metastasis (TNM) classification system, T0 means there is
No evidence of primary tumor
Explanation:
T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis.
300
A decrease in circulating white blood cells (WBCs) is referred to as
Leukopenia
Explanation:
A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.
301
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
Explanation:
A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.
302
Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
"I'm worried I'll expose my family members to radiation."
Explanation:
The client undergoing external radiation therapy requires further teaching when he voices a concern that he might expose his family to radiation. Internal radiation, not external radiation, poses a risk to the client's family. The client requires no further teaching if he states that he should wash his skin with mild soap and water, wear protective clothing when outside, and avoid using a heating pad.
303
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?
Tumor pressure against normal tissues
Explanation:
Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.
304
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
Explanation:
Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
305
The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice?
eats red meat such as steaks or hamburgers every day
Explanation:
Dietary substances such as nitrate–containing and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. Alcohol consumption recommendations include drink no more than one drink per day for women or two per day for men.
306
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The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply.
dietary substances
environmental factors
viruses
gender
age
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Carcinogens include chemical agents, environmental factors, dietary substances, viruses, lifestyle factors, and medically prescribed interventions. Although age and gender may increase a person's risk for developing certain types of cancer, they are not carcinogens in and of themselves.
307
An oncology nurse is caring for a client who is taking antineoplastic agents. What symptoms would the nurse consider with tumor lysis syndrome when monitoring this client?
symptoms of gout
Explanation:
The nurse monitors the client being administered an antineoplastic agent for symptoms of gout, which include increased uric acid levels, joint pain, and edema, with the consideration of tumor lysis syndrome. Administering antineoplastic agents does not cause hypertension, constipation, or anemia.
308
A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:
chemotherapy exposure and risk factors.
Explanation:
The raised toilet lid exposes the child playing in the bathroom to the risk of inhaling or ingesting chemotherapy agents. The nurse should modify her teaching plan to include content related to chemotherapy exposure and its associated risk factors. Because the client has received chemotherapy, the plan should already include information about expected adverse effects, signs and symptoms of infection, and reinforcement of the medication regimen.
309
A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention?
The I.V. site is red and swollen.
Explanation:
A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.
310
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods.
Explanation:
The nurse advises a client undergoing chemotherapy to avoid hot and very cold liquids and spicy and fatty foods. The nurse also encourages the client to have small meals and appropriate fluid intake.
311
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered
Explanation:
The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.
312
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
“I guess the doctor could not remove the entire tumor.”
Explanation:
Debulking is a reference made when a tumor cannot be completely removed, often due to its extension far into healthy tissue. Without complete removal, this is not a cure and, the cancer cells will continue to replicate and require adjuvant therapies to prevent further invasion. The physician, not the nurse, will need to clarify the details of the surgery.
313
The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome?
An aunt and uncle diagnosed with cancer
Explanation:
The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.
314
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A client has been receiving chemotherapy. Upon assessing the client during morning rounds, the nurse notes the client is now bleeding from intravenous and venipuncture sites. Stool is positive for occult blood. The client is requesting to sit in a chair for a meal. The nurse implements the following interventions: (Select all that apply.)
Monitor vital signs once a shift.
Assess level of consciousness.
Assist the client to a chair.
Apply pressure to the bleeding sites.
Check intake and output records.
```
The client may be experiencing disseminated intravascular coagulation (DIC) following the cancer experience and chemotherapy treatment. When the nurse notes the client is experiencing unexpected and abnormal bleeding, the nurse will assess level of consciousness (the client can be bleeding in the brain) and intake and output records (the client may experience decreased urinary output as a result of poor renal perfusion). The nurse applies pressure to venipuncture sites to decrease bleeding. The nurse will assess vital signs more frequently than once a shift. The nurse minimizes client activities to decrease risk for injury.
315
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of
graft-versus-host disease.
Explanation:
Graft-versus-host disease is a major cause of morbidity and mortality in clients who have had allogeneic transplant. Clinical manifestations of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea, abdominal pain, and hepatomegaly.
316
A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included?
eyelids
Explanation:
The sclera does not attach to the eyelids. The sclera protects structures in the eye, and connects directly to the cornea, anterior chamber, iris, and pupil.
317
A legally blind client is in pre-op area prior to an appendectomy. What steps does the nurse take to effectively communicate with this client ?
Notify the client prior to touching the client.
Explanation:
The nurse should announce upon arrival the bedside every time because many voices sound similar. The nurse should use the client's name initially so the client knows the nurse is communicating with the client directly. The nurse should speak before touching the client as not to startle the client. The nurse should notify the client when approaching and leaving the bedside each time. Orient the client to their surroundings using verbal descriptions and directions such as left, or right.
318
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
demonstrate eyedrop instillation.
Explanation:
Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.
319
A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:
ptosis
Explanation:
Ptosis is drooping or falling of the upper or lower eyelid. Ptolemy is not a medical condition. Proptosis is the extended or protruded upper eyelid that delays closing or remains partially open. Nystagmus is uncontrolled oscillating movement of the eyeball.
320
The nurse is giving a visual field examination to a 55-year-old male client. The client asks what this test is for. What would be the nurse's best answer?
“This test measures peripheral vision and detects gaps in the visual field.”
Explanation:
A visual field examination or perimetry test measures peripheral vision and detects gaps in the visual field.
321
The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?
Marked blurring of vision
Explanation:
Glaucoma is often called the “silent thief of sight” because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or “halos” around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.
322
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry red in color?
Hemangioma
Explanation:
Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of skin aging or a lipid disorder. Molluscum contagiosum lesions are flat, symmetric growths along the lid margin caused by a virus that can result in conjunctivitis and keratitis if the lesion grows into the conjunctival sac.
323
A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage?
21 mm Hg or higher
Explanation:
Intraocular pressure of greater than 21 mm Hg is a sign of primary open-angle glaucoma.
324
A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection?
To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid.
Explanation:
Avoid contaminating the medication dropper or tube by holding the tip above the eye and adjacent tissue. Using a separate container of ophthalmic medication for each client prevents cross-contamination. Maintaining asepsis prevents the introduction and transmission of infection. Handwashing prevents infection.
325
A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following?
Chlamydia trachomatis
Explanation:
Common organisms isolated are Streptococcus pneumoniae, Hemophilus influenzae, and Staphylococcus aureus. Two sexually transmitted agents associated with conjunctivitis are Chlamydia trachomatis and Neisseria gonorrhoeae.
326
The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?
Acute angle-closure glaucoma
Explanation:
Acute angle-closure glaucoma is an emergency where the nurse should refer the client for medical treatment immediately because vision may be permanently lost in 1 to 2 days. Treatment of a chalazion is not necessary if the cyst is small and does not interfere with vision. Occurrence of a hordeolum or blepharitis is not an emergency and may be treated with warm soaks or frequent washing of the eye.
327
Which medication classification increases aqueous fluid outflow in the client with glaucoma?
Cholinergics
Explanation:
Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.
328
To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Explanation:
NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.
329
Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?
Scleral buckle
Explanation:
The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.
330
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?
Hemangioma
Explanation:
Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye; these commonly appear as a result of the aging of the skin or a lipid disorder. Nevi are freckles.
331
During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ?
Mucopurulent ocular discharge
Explanation:
Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases.
332
Retinoblastoma is the most common eye tumor of childhood. It is hereditary in which percentage of cases?
30 to 40
Explanation:
Retinoblastoma can be hereditary or nonhereditary. It is hereditary in 30% to 40% of cases. All bilateral cases are hereditary.
333
The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient?
Blurred vision results after application.
Explanation:
Ophthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration than eye drops. The major disadvantage of ointments is the blurred vision that results after application. In general, eyelids and eyelid margins are best treated with ointments.
334
A nurse instructs a client to refrain from blinking after administering eye drops based on which rationale?
Blinking causes the eye drop to be expelled from the conjunctival sac.
Explanation:
Blinking expels an instilled eye drop from the conjunctival sac, which interferes with the efficacy of the medication. Blood-ocular barriers keep foreign substances from entering the eye. The size of the conjunctival sac does change with blinking. It can hold only 50 uL.
335
Which group of medications causes pupillary constriction?
Miotics
Explanation:
Miotics cause pupillary constriction. Mydriatics cause pupillary dilation. Beta-blockers decrease aqueous humor production. Adrenergic agonists increase aqueous outflow but primarily decrease aqueous production with an action similar to that of beta-blockers and carbonic anhydrase inhibitors.
336
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?
Coumadin
Explanation:
It has been common practice to withhold any anticoagulant therapy such as Coumadin to reduce the risk for retrobulbar hemorrhage (after retrobulbar injection) for 5 to 7 days before surgery.
337
A nurse is performing an eye examination. Which question would not be included in the examination?
"Are you able to raise both eyebrows?"
Explanation:
Asking to raise both eyebrows is a test for cranial nerve VII, the facial nerve, and would not be included in an eye assessment.
338
The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?
Extraocular muscle function
Explanation:
The nurse is testing the client's extraocular eye muscle function by having the client follow an object through the six cardinal directions of gaze (up, down, right, left, and both diagonals). Pupillary reaction is tested using a penlight. The nurse observes the position of the eyelids for drooping. The nurse asks a client to stare at an object and then each eye is covered and then uncovered quickly while the examiner looks for any shifts in the eye and oscillations in the eyeball.
339
The nurse is teaching the client to instill eye drops. Which statement is correct?
"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle."
Explanation:
Eye medications should be administered using an aseptic technique. Therefore, handwashing and not contaminating the tip of the medication container is important. Eye drops are administered after eye ointments, not before. The waiting time between administering eye ointments is 10 minutes. The client should also be taught to wait 5 minutes between the instillation of different eye drops. Contact lenses should be removed before eye drops or ointment is applied.
340
A client’s vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse?
“You see an object from 20 feet away that a person with normal vision sees from 200 feet away.”
Explanation:
The fraction 20/20 is considered the standard of normal vision. Most people, positioned 20 feet from an eye chart, can see the letters designated as 20/20 from a distance of 20 feet.
341
Which term refers to swelling of the optic disc due to increased intracranial pressure?
Papilledema
Explanation:
Papilledema is swelling of the optic disc due to increased intracranial pressure. Chemosis is edema of the conjunctiva. Ptosis is a drooping eyelid. Photophobia is ocular pain on exposure to light.
342
Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?
Viral
Explanation:
Viral conjunctivitis is usually preceded by symptoms of an upper respiratory infection. The other types of conjunctivitis are not usually preceded by symptoms of a respiratory infection.
343
A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?
Adhere to the medication regimen.
Explanation:
All of the teaching points are important but the most important is emphasizing the strict adherence to the medication regimen because glaucoma cannot be cured but its progression can be slowed
344
A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?
25 mm Hg
Explanation:
Normally, intraocular pressure (IOP) ranges between 10 to 21 mm Hg. Any reading greater than 21 mm Hg indicates increased IOP.
345
The nurse should monitor for which manifestation in a client who has undergone LASIK?
Halos and glare
Explanation:
Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.
346
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:
10 to 20 mm Hg.
Explanation:
Normally, pressure in the anterior chamber of the eye remains relatively constant at 10 to 20 mm Hg.
347
The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder?
Prolonged use of corticosteroids
Explanation:
Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.
348
To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it:
Up and backward.
Explanation:
The tympanic membrane is inspected with an otoscope, which should be held in the examiner's right hand. Using the opposite hand, the auricle is grasped and gently pulled upward and back to straighten the canal in an adult.
349
The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?
The power of the lens to accommodate will be decreased.
Explanation:
In the older adult, the accommodative power of the lens decreases, resulting in the need to hold reading materials at increasing distances to focus. Orbital fat and skin elasticity decrease. The depth of the eyeball does not change with age.
350
A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?
Hemorrhage
Explanation:
The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting may be common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
351
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
Retinal Angiography
Explanation:
The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.
352
A nurse is giving discharge teaching to a client with an eye injury. Which statement about preventing eye injuries should the nurse include?
"Direct all spray nozzles away from your face before spraying."
Explanation:
The nurse should instruct the client to direct all spray nozzles away from his face before spraying. The nurse should instruct the client to use a flashlight if checking a car battery at night to decrease the risk of explosion. Safety goggles should be worn at all times in a workshop by everyone; flying debris can cause injuries at any time. The client should never stand next to or in front of a moving lawn mower. Debris can be ejected from the blades and cause injury.
353
A client is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride per orders to assess visual acuity. The client requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse?
“Prescriptions of this medication are generally not given because it can cause corneal problems.”
Explanation:
Proparacaine hydrochloride can cause corneal softening and other complications if overused. Clients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions, and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the client that you will let the doctor know does not provide the education needed about this medication.
354
A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?
To prevent vision loss
Explanation:
Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.
355
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests?
Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss
Explanation:
Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.
356
It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?
20/200
Explanation:
Legal blindness is a condition of impaired vision in which a person has best corrected visual acuity that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less (Prevent Blindness America, 2012).
357
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?
Myopia
Explanation:
Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which affects both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly but near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.
358
Edema of the conjunctiva is termed
chemosis.
Explanation:
Chemosis is a common manifestation of pinkeye. Papilledema refers to swelling of the optic disk due to increased intracranial pressure. Proptosis is the downward displacement of the eyeball. Strabismus is a condition in which there is a deviation from perfect ocular alignment.
359
Which of the following is the main refracting surface of the eye?
Cornea
Explanation:
The cornea is a transparent, avascular, domelike structure that covers the iris, pupil, and anterior chamber. It is the most anterior portion of the eyeball and is the main refracting surface of the eye. The iris is the colored part of the eye. The pupil is a space that dilates and constricts in response to light. Normal pupils are round and constrict symmetrically when a bright light shines on them. The conjunctiva provides a barrier to the external environment and nourishes the eye.
360
A client is color blind. The nurse understands that this client has a problem with:
cones.
Explanation:
Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.
361
Which term refers to the absence of the natural lens?
Aphakia
Explanation:
When a cataract is extracted and an intraocular lens implant is not used, the client demonstrates aphakia. Scotoma refers to a blind or partially blind area in the visual field. Keratoconus refers to a cone-shaped deformity of the cornea. Hyphema refers to blood in the anterior chamber of the eye.
362
A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?
hyperopia
Explanation:
Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.
363
The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform?
Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye
Explanation:
Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.
364
A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure?
Improve outflow drainage
Explanation:
Laser iridotomy or standard iridotomy is a surgical procedure that provides additional outlet drainage of aqueous humor. This is done to lower the IOP as quickly as possible since permanent vision loss can occur in 1 to 2 days. Once optic nerve damage occurs, it cannot be reversed, and vision is not restored. Pain that occurs with rising IOP will be controlled once pressure is lowered through improved outflow drainage.
365
The nurse is providing care to a client who has been admitted to the hospital for treatment of an infection. The client is visually impaired. Which of the following would be most appropriate for the nurse to do when interacting with the client?
Face the client when speaking directly to him.
Explanation:
When interacting with a client with a visual impairment, the nurse should face the client and speak directly to the client using a normal tone of voice. It is not necessary to raise the voice unless the client asks the nurse to do so and it is not necessary to avoid the terms, "see" or "look" when interacting with the client. The nurse should identify himself or herself when approaching the client and before making any physical contact.
366
The school nurse is testing the kindergarten class with the Snellen chart. What is the nurse testing the children for?
Visual acuity
Explanation:
Th Snellen eye chart is a simple screening tool for determining visual acuity, the ability to see far images clearly.
367
A 68-year-old client reports a change in vision when driving during the night. Which strategies would the nurse recommend to mitigate this problem?
Recommend contrast sensitivity testing measures to determine visual function.
Explanation:
With aging, structural and functional changes occur in the eye. Clients having visual changes while driving should have a contrast sensitivity testing done. Contrast sensitivity testing measures visual acuity in different degrees of light and dark, which determines visual function. Glare testing is also used to determine visual function. Those affected by loss of contrast sensitivity and glare have difficulty functioning in low light, or driving at night or in foggy conditions. With the results from testing, appropriate strategies can be recommended. Presbyopia, the loss of accommodative power in the lens, interferes with the ability to adequately focus (difficulty seeing small print) and is the factor responsible for most older adults requiring some form of corrective lenses. Presbyopia interferes with vision during the day and night. An eye shield is proposed for clients' postoperative management after cataract surgery. Wearing yellow tinted, not darkly tinted, glasses may help cut night glare during driving.
368
A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign?
The presence of halos around lights
Explanation:
Colored halos around lights is a classic symptom of acute-closure glaucoma.
