Exam FUCKING 1 Flashcards
1
Q
A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?
a. Lives in a nursing home
b. Lives with a spouse
c. Lives divorced
d. Lives alone
A
ANS B:
In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women,
71% of older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all
older adults resided in institutions such as nursing homes or centers. Most older adults have lost a
spouse due to death rather than divorce
2
Q
A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
a. Should be standardized because most geriatric patients have the same needs
b. Needs to be individualized to the patient’s unique needs
c. Focuses on the disabilities that all aging persons face
d. Must be based on chronological age alone
A
Every older adult is unique, and the nurse needs to approach each one as a unique individual. The
nursing care of older adults poses special challenges because of great variation in their physiological,
cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence.
Chronological age often has little relation to the reality of aging for an older adult.
3
Q
Which information from a co-worker on a gerontological unit will cause the nurse to intervene?
a. Most older people have dependent functioning.
b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision.
d. Most older people should be encouraged to have independence
A
ANS: A
Most older people remain functionally independent despite the increasing prevalence of chronic
disease; therefore, this misconception should be addressed. It is critical for you to respect older adults
and actively involve them in care decisions and activities. You also need to identify an older adult’s
strengths and abilities during the assessment and encourage independence as an integral part of your
plan of care
4
Q
A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment
findings are consistent with the nurse’ssuspicions?
a. Flea bites and lice infestation
b. Left at a grocery store
c. Refuses to take a bath
d. Cuts and bruises
A
ANS: A
Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect
infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as
a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities
such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse
includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs,
fractures, lacerations, rope burns, and untreated injuries
5
Q
A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to
use?
a. Provide several topics of discussion at once to promote independence and making choices.
b. Avoid uncomfortable silences after questions by helping patients complete their statements.
c. Ask patients to recall past experiences that correspond with their interests.
d. Speak in a high pitch to help patients hear better
A
ANS: C
Teaching strategies include the use of past experiences to connect new learning with previous
knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time
in which to respond because older adults’ reaction times are longer than those of younger persons,
and keeping the tone of voice low; older adults are able to hear low sounds better than high frequency sounds
6
Q
An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is
concerned about the patient’s ability to care for self, especially during this convalescence. What
should the nurse do?
a. Stress that older patients usually ask for help when needed.
b. Inform the family that placement in a nursing center is a permanent solution. c. Tell the family to enroll the patient in a ceramics class to maintain quality of life.
d. Provide information and answer questions as family members make choices among care options
A
ANS: D
Nurses help older adults and their families by providing information and answering questions as they
make choices among care options. Some older adults deny functional declines and refuse to ask for
assistance with tasks that place their safety at great risk. The decision to enter a nursing center is
never final, and a nursing center resident sometimes is discharged to home or to another less-acute
residence. What defines quality of life varies and is unique for each person
7
Q
What is the best suggestion a nurse could make to a family requesting help in selecting a local
nursing center?
a.
Have the family members evaluate nursing home staff according to their ability to get tasks done efficient
safely.
b. Make sure that nursing home staff members get patients out of bed and dressed according to staff’s prefer
c. Explain that it is important for the family to visit the center and inspect it personally.
d. Suggest a nursing center that has standards as close to hospital standards as possible
A
ANS: C
An important step in the process of selecting a nursing home is to visit the nursing home. The nursing
home should not feel like a hospital. It is a home, a place where people live. Members of the nursing
home staff should focus on the person, not the task. Residents should be out of bed and dressed
according to their preferences, not staff preferences.
8
Q
A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The
nurse is discussing health care services and possible long-term living arrangements with thepatient’s
only son. What will the nurse suggest?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
d. That placement is irrelevant because the patient is retreating to a place of inactivity
A
ANS: C
Some family caregivers consider nursing center placement when in-home care becomes increasingly
difficult or when convalescence from hospitalization requires more assistance than the family is able
to provide. An apartment setting and the use of home health visits are not appropriate because living
at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning
9
Q
A nurse is caring for an older adult. Which goal is priority?
a. Adjusting to career
b. Adjusting to divorce
c. Adjusting to retirement
d. Adjusting to grandchildren
A
ANS: C
Adjusting to retirement is one of the developmental tasks for an older person. A young or middle aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
10
Q
A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing?
a. Loss of finances through changes in income
b. Loss of relationships through death
c. Loss of career through retirement
d. Loss of home through relocation
A
ANS: B
The universal loss for older adults usually revolves around the loss of relationships through death.
Life transitions, of which loss is a major component, include retirement and the associated financial
changes, changes in roles and relationships, alterations in health and functional ability, changes in
one’s social network, and relocation. However, these are not the universal loss
11
Q
A nurse is discussing sexuality with an older adult. Which action will the nurse take?
a. Ask closed-ended questions about specific symptoms the patient may experience.
b. Provide information about the prevention of sexually transmitted infections .c. Discuss the issues of sexuality in a group in a private room.
d. Explain that sexuality is not necessary as one ages.
A
ANS: B
Include information about the prevention of sexually transmitted infections when appropriate. Openended questions inviting an older adult to explain sexual activities or concerns elicit more
information than a list of closed-ended questions about specific activities or symptoms. You need to
provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and
the need to express sexual feelings remain throughout the human life span.
12
Q
A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4
A
ANS: BHeart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents).
13
Q
A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men
A
ANS: C
Loss of skin elasticity is a common finding in the older adult. Other common findings include
pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair:
decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles
14
Q
An older-adult patient in no acute distress reports being less able to taste and smell. What is the
nurse’s bestresponse to this information?
a. Notify the health care provider immediately to rule out cranial nerve damage.
b. Schedule the patient for an appointment at a smell and taste disorders clinic.c. Perform testing on the vestibulocochlear nerve and a hearing test.
d. Explain to the patient that diminished senses are normal findings.
A
ANS: D
Diminished taste and smell senses are common findings in older adults. Scheduling an appointment
at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out
cranial nerve damage is unnecessary at this time as per the information provided
15
Q
A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills
A
ANS: C
Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment,
such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are
not normal aging changes and require further investigation of underlying causes
16
Q
An older patient with dementia and confusion is admitted to the nursing unit after hip
replacement surgery. Which action will the nurse include in the plan of care?
a. Keep a routine.
b. Continue to reorient.
c. Allow several choices.
d. Socially isolate patient
A
ANS: A
Patients with dementia need a routine. Continuing to reorient a patient with dementia is
nonproductive and not advised. Patients with dementia need limited choices. Social interaction based
on the patient’s abilities is to be promoted
17
Q
A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse
will be assisting the patient with which activity?
a. Taking a bath
b. Getting dressed
c. Making a phone call
d. Going to the bathroom
A
ANS: CInstrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare
meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and
toileting) are essential to independent living
18
Q
A male older-adult patient expresses concern and anxiety about decreased penile firmness during
an erection. What is the nurse’s best response?
a. Tell the patient that libido will always decrease, as well as the sexual desires.
b. Tell the patient that touching should be avoided unless intercourse is planned.
c. Tell the patient that heterosexuality will help maintain stronger libido.
d. Tell the patient that this change is expected in aging adults
A
ANS: D
Aging men typically experience an erection that is less firm and shorter acting and have a less
forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of
libido. However, for both men and women sexual desires, thoughts, and actions continue throughout
all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of
intercourse. Touch complements traditional sexual methods or serves as an alternative sexual
expression when physical intercourse is not desired or possible. Clearly not all older adults are
heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender
individuals and their health care needs.
19
Q
. A patient asks the nurse what the term polypharmacy means. Which information should the nurse
share with the patient?
a. This is multiple side effects experienced when taking medications.
b. This is many adverse drug effects reported to the pharmacy.
c. This is the multiple risks of medication effects due to aging.
d. This is concurrent use of many medications
A
ANS: D
Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with
side effects, adverse drug effects, or risks of medication use due to aging
20
Q
An outcome for an older-adult patient living alone is to be free from falls. Which statement
indicates the patient correctly understands the teaching on safety concerns?
a. “I’ll take my time getting up from the bed or chair.”
b. “I should dim the lighting outside to decrease the glare in my eyes.”
c. “I’ll leave my throw rugs in place so that my feet won’t touch the cold tile.”
d. “I should wear my favorite smooth bottom socks to protect my feet when walking around.”
A
ANS: APostural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a
correct understanding of this concept. Environmental hazards outside and within the home such as
poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs
are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls
and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also
contributes to falls.
21
Q
A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action
will the nurse take?
a. Review the patient’s list of medications at each visit.
b. Teach that polypharmacy is to be avoided at all cost.
c. Avoid information about adverse effects.
d. Focus only on prescribed medications
A
ANS: A
Strategies for reducing the risk for adverse medication effects include reviewing the medications with
older adults at each visit; examining for potential interactions with food or other medications;
simplifying and individualizing medication regimens; taking every opportunity to inform older adults
and their families about all aspects of medication use; and encouraging older adults to question their
health care providers about all prescribed and over-the-counter medications. Although polypharmacy
often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary
when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse
drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion
of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all
medications—both prescribed medications and over-the-counter medications and herbal options
22
Q
An older-adult patient has developed acute confusion. The patient has been on tranquilizers for
the past week. The patient’s vital signs are normal. What should the nurse do?
a. Take into account age-related changes in body systems that affect pharmacokinetic activity.
b. Increase the dose of tranquilizer if the cause of the confusion is an infection.
c. Note when the confusion occurs and medicate before that time.
d. Restrict phone calls to prevent further confusion
A
ANS: A
Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or
exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into
account age-related changes in body systems that affect pharmacokinetic activity. When confusion
has a physiological cause (such as an infection), specifically treat that cause, rather than the confused
behavior. When confusion varies by time of day or is related to environmental factors,
nonpharmacological measures such as making the environment more meaningful, providing adequate
light, etc., should be used. Making phone calls to friends or family members allows older adults to
hear reassuring voices, which may be beneficial.
23
Q
Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. Confusionb. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago
A
ANS: A
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause
requires further assessment. There may be another reason for the confusion. Confusion is not a
normal finding in the older adult, even though it is commonly seen with concurrent infections.
Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have
lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed
after the acute physiological concern in this case
24
Q
Which patient statement is the most reliable indicator that an older adult has the correct
understanding of health promotion activities?
a. “I need to increase my fat intake and limit protein.”
b. “I still keep my dentist appointments even though I have partials now.”
c. “I should discontinue my fitness club membership for safety reasons.”
d. “I’m up-to-date on my immunizations, but at my age, I don’t need the influenza vaccine.”
A
ANS: B
General preventive measures for the nurse to recommend to older adults include keeping regular
dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercisingregularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis,
shingles, and pneumococcal disease.
25
A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and
has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that
does not have public transportation. Which psychosocial change does the nurse focus on as
a priority?
a. Sexuality
b. Retirement
c. Environment
d. Social isolation
ANS: D
The highest priority at this time is the potential for social isolation. This woman does not know how
to drive and lives in a rural community that does not have public transportation. All of these factors
contribute to her social isolation. Other possible changes she may be going through right now include
sexuality related to her advanced age and recent death of her spouse; however, this is not the priority
at this time. She has been retired for 5 years, so this is also not an immediate need. She may
eventually experience needs related to environment, but the data do not support this as an issue at this
time
26
A recently widowed older-adult patient is dehydrated and is admitted to the hospital for
intravenous fluid replacement. During the evening shift, the patient becomes acutely confused.
Which possible reversible causes will the nurse consider when assessing this patient? (Select all that
apply.)
a. Electrolyte imbalance
b. Sensory deprivation
c. Hypoglycemia
d. Drug effects
e. Dementia
ANS: A, B, C, D
Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due
to a physiological event. Physiological causes include electrolyte imbalances, untreated pain,
infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and
cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such
as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or
psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible
cerebral dysfunction
27
A nurse is caring for a young adult. Which goal is priority?
a. Maintain peer relationships.
b. Maintain family relationships.
c. Maintain parenteral relationships.
d. Maintain recreational relationships
ANS: B
Family is important during young adulthood. Challenges may include the demands of working and
raising families. Peer is more important in the adolescent years. Young adults are much freer from
parental control. While recreation is important, the family and work are the priorities in young adults.
28
The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local
restaurant. He states that he would like to get a better job but has no education. How can the
nurse best assist this patient psychosocially?
a. By providing information and referrals
b. By focusing on the patient’s medical diagnoses
c. By telling the patient that he needs to go back to school
d. By expecting the patient to be flexible in decision making
ANS: A
Support from the nurse, access to information, and appropriate referrals provide opportunities for
achievement of a patient’s potential. Health is not merely the absence of disease (focusing on
medical diagnoses) but involves wellness in all human dimensions. Telling a patient what to do (go
back to school) is inappropriate. Each person (not the nurse) needs to make these decisions based on
individual factors. Insecure persons tend to be more rigid in making decisions
29
Which goal is priority when the nurse is caring for a middle-aged adult?
a. Maintain immediate family relationships.
b. Maintain future generation relationships.
c. Maintain personal career relationships.
d. Maintain work relationships.
ANS: B
Many middle-aged adults find particular joy in helping their children and other young people become
productive and responsible adults. While immediate family is important, this goal is priority in young
adults, not as important in middle-aged adults. During this period, personal and career achievements
have often already been experienced; therefore, these goals are not priority
30
A nurse is teaching young adults about health risks. Which statement from a young adult indicates
a correct understanding of the teaching?
a. “It’s probably safe for me to start smoking. At my age, there’s not enough time for cancer to develop.”
b. “My mother had appendicitis so this increases my chance for developing appendicitis.”
c. “Controlling the amount of stress in my life may decrease the risk of illness.”
d. “I don’t do drugs. I do drink coffee, but caffeine is not a drug.
ANS: C
Lifestyle habits that activate the stress response increase the risk of illness; so, controlling this will
decrease risk. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease
as well as cancer in smokers and in individuals who receive secondhand smoke. The presence of
certain chronic illnesses (not acute illnesses—appendicitis) in the family increases the family
member’s risk of developing a disease. Caffeine is a naturally occurring legal stimulant that is readily
available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous
system; it also increases gastric acid secretion, heart rate, and basal metabolic rate
31
```
A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the
nurse include?
a. Retirement
b. Menopause
c. Climacteric factors
d. Unplanned pregnancies
```
ANS: D
Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for
the mother (young adult), infant, and family. Retirement is an issue for middle-aged, not young
adults. The onset of menopause and the climacteric affect the sexual health of the middle-aged adult,
not the young adult
32
```
A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population
should the nurse focus on most for IVP?
a. White males
b. Pregnant females
c. Middle-aged adults
d. Nonsubstance abusers
```
ANS: BThe greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6%
greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults,
and nonsubstance abusers are not as high risk as pregnant women
33
A patient states that she is pregnant and concerned because she does not know what to expect, and
she wants her husband to play an active part in the birthing process. Which information should the
nurse share with the patient?
a. Lamaze classes can prepare pregnant women and their partners for what is coming.
b. The frequency of sexual intercourse is key to helping the husband feel valued.
c. After the birth, the stress of pregnancy will disappear and will be replaced by relief.
d. After the baby is born, the wife should accept the extra responsibilities of motherhood
ANS: A
Childbirth education classes (like Lamaze) can prepare pregnant women, their partners, and other
support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is
as important as the type or frequency of sexual intercourse to young adults; however, this does not
relate to the issue the patient reports (lack of knowledge and participation). The stress that many
women experience after childbirth has a significant impact on the health of postpartum women.
Ideally partners should share all responsibilities; however, this does not relate to the patient’s
concerns
34
Which information from the nurse indicates a correct understanding of emerging adulthood?a. It is a type of young adulthood.
b. It is a type of extended adolescence.
c. It is a type of independent exploration.
d. It is a type of marriage and parenthood
ANS: C
This newly identified stage of development from age 18 to 25 (emerging adulthood) has been
described as neither an extended adolescence, as it is much freer from parental control and is much
more a period of independent exploration, nor young adulthood, as most young people in their
twenties have not made the transitions historically associated with adult status, especially marriage
and parenthood.
35
A nurse is planning care for a 30 year old. Which goal is priority?
a. Refine self-perception.
b. Master career plans.
c. Examine life goals.
d. Achieve intimacy
ANS: B
From 29 to 34, the person directs enormous energy toward achievement and mastery of the
surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals andrelationships. Between the ages of 23 and 28, the person refines self-perception and ability for
intimacy.
36
A nurse is planning care for young-adult patients. Which information should the nurse consider
when planning care?
a. Fertility issues do not occur in young adulthood.
b. Young adults tend to suffer more from severe illness.
c. Substance abuse is easy to observe in young-adult patients.
d. Young adults are quite active but are at risk for illness in later years
ANS: D
Young adults are generally active and experience severe illnesses less frequently. However, their
lifestyles may put them at risk for illnesses or disabilities during their middle or older-adult years. An
estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Substance
abuse is not always diagnosable, particularly in its early stages
37
During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old
female patient reports pain and redness in the right breast. Which action is best for the nurse to take
in response to this finding?
a. Assess the patient as thoroughly as possible.b. Explain to the patient that breast tenderness is normal at her age.
c. Tell the patient that redness is not a cause for concern and is quite common.
d. Inform her that redness is the precursor to normal unilateral breast enlargement
ANS: A
A comprehensive assessment offers direction for health promotion recommendations, as well as for
planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal
physical assessment findings in the middle-aged adult. Increased size of one breast is an abnormal
physical assessment finding in the middle-aged adult
38
A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and
hot flashes. Which information should the nurse share with the patient?
a. The patient’s assessment points toward normal menopause.
b. Those symptoms are normal when a woman undergoes the climacteric.
c. An assessment is not really needed because these problems are normal for older women.
d. The patient should stop regular exercise because that is probably causing these symptoms
ANS: A
The most significant physiological changes during middle age are menopause in women and the
climacteric in men. Menopause typically occurs between 45 and 60 years of age. The nurse should
continue with the examination because a comprehensive assessment offers direction for health
promotion recommendations, as well as for planning and implementing any acutely needed
interventions. Exercise should not be stopped, especially in middle-aged adults
39
The nurse is teaching a class to pregnant women about common physiological changes during
pregnancy. Which information should the nurse include in the teachingsession?
a. Pregnancy is not a time to be having sexual activity.
b. Urinary frequency will occur early in the pregnancy.
c. Breast tenderness should be reported as soon as possible.
d. Late in the pregnancy Braxton Hicks contraction may occur
ANS: D
During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short
contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have
morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that
sexual activity will not harm the fetus
40
A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response
will the nurse most expect from this patient?
a. “I should consider participating in a health fair about safe sun practices.”
b. “I’ll make an appointment with my doctor right away for a full skin check.”
c. “I’ve had this mole my whole life. So what if it changed color? My skin is fine."
d. “I have a mole that has been bothering me. I’ll call my family doctor for an appointment to get it checked
ANS: C
Most typically young adults would say that their skin is fine. Young adults often ignore physical
symptoms and often postpone seeking health care. Making an appointment right away with the
doctor and participating in health fairs are not typical behaviors of young adults for the same reason
41
Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and
decreased range of joint motion. Which area is priority?
a. Abuse potential
b. Fall precautions
c. Stroke prevention
d. Self-esteem issues
ANS: B
With uneven weight bearing and decreased range of joint motion, falling is a priority. Abuse
potential would indicate other findings such as bruising or unkept appearance. While stroke
prevention is important in a middle-aged adult, these are not the signs of stroke. While self-esteem
issues may arise from physical changes, safety is a priority over self-esteem issues
42
A young-adult patient is brought to the hospital by police after crashing the car in a high-speed
chase when trying to avoid arrest for spousal abuse. Which action should the nursetake?
a. Question the patient about drug use.
b. Offer the patient a cup of coffee to calm nerves.
c. Discretely assess the patient for sexually transmitted infections.
d. Deal with the issue at hand, not asking about previous illnesses
ANS: A
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are
reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a
naturally occurring legal stimulant that stimulates the central nervous system and is not the choicefor
calming nerves. Although sexually transmitted infections occur in the young adult, this is not an
action a nurse should take in this situation. The nurse may obtain important information by making
specific inquiries about past medical problems, changes in food intake or sleep patterns, and
problems of emotional lability
43
A nurse determines that a middle-aged patient is a typical example of the “sandwich generation.”
What did the nurse discover the patient is caught between?
a. Job responsibilities or family responsibilities
b. Stopping old habits and starting new ones
c. Caring for children and aging parents
d. Advancing in career or retiring
ANS: C
Middle-aged adults also begin to help aging parents while being responsible for their own children,
placing them in thesandwich generation. It does not include job and family responsibilities; old
habits and new ones; or career and retiring
44
A nurse is assessing a middle-aged patient’s barriers to change in eating habits. Which areas will
the nurse assess that are external barriers? (Select all that apply.)
a. Lack of facilities
b. Lack of materials
c. Lack of knowledge
d. Lack of social supports
e. Lack of short- and long-term goals
ANS: A, B, D
External barriers to change include lack of facilities, materials, and social supports. Internal barriers
are lack of knowledge, insufficient skills, and undefined short- and long-term goals
45
A home health nurse is providing care to a middle-aged couple with children at home. The patient
has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.)a. Adherence to treatment and rehabilitation regimens
b. Coping mechanisms of patient and family
c. Need for community services or referrals
d. Knowledge base of patient only
e. Use of a doula for care
ANS: A, B, C
Along with the current health status of the chronically ill middle-aged adult, you need to assess the
knowledge base of both the patient and family. In addition, you must determine the coping
mechanisms of the patient and family; adherence to treatment and rehabilitation regimens; and the
need for community and social services, along with appropriate referrals. A doula is a support person
to be present during labor to assist women who have no other source of support
46
A nurse is providing prenatal care to a first-time mother. Which information will the nurse share
with the patient? (Select all that apply.)
a. Regular trend for postpartum depression
b. Protection against urinary infection
c. Strategies for empty nest syndrome
d. Exercise patterns
e. Proper diet
ANS: B, D, E
Prenatal care includes a thorough physical assessment of the pregnant woman during regularly
scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections
that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are
important for a pregnant woman. Empty nest syndrome occurs as children leave the home.
Postpartum depression is rare.
47
A patient has dehydration. While planning care, the nurse considers that the majority of the
patient’s total water volume exists in with compartment?
a. Intracellular
b. Extracellular
c. Intravascular
d. TranscellulaR
ANS: A
Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water.
Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid
(liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular
compartment
48
The nurse is teaching about the process of passively moving water from an area of lowerparticle
concentration to an area of higher particle concentration. Which process is the nursedescribing?
a. Osmosisb. Filtration
c. Diffusion
d. Active transport
ANS: A
The process of moving water from an area of low particle concentration to an area of higher particle
concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher
pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles
down the concentration gradient (from areas of higher concentration to areas of lower concentration).
Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes
across cell membranes against the concentration gradient (from areas of lower concentration to areas
of higher concentration
49
The nurse observes edema in a patient who has venous congestion from right heart failure.Which
type of pressure facilitated the formation of the patient’s edema?
a. Osmotic
b. Oncotic
c. Hydrostatic
d. Concentration
ANS: CVenous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes
edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic
pressures involve the concentrations of solutes and can contribute to edema in other situations, such
as inflammation or malnutrition. Concentration pressure is not a nursing term
50
```
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which directionwill
the fluid shift?
a. From intracellular to extracellular
b. From extracellular to intracellular
c. From intravascular to intracellular
d. From intravascular to interstitial
```
ANS: A
Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A
hypertonic solution has a concentration greater than normal body fluids, so water will shift out of
cells because of the osmotic pull of the extra particles. Movement of water from the extracellular
(intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution
of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic
and osmotic pressures
51
```
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse
perform the steps starting with the first one?
1. Clean site.
2. Select vein.
3. Apply tourniquet.
4. Release tourniquet.
5. Reapply tourniquet.
6. Advance and secure.
7. Insert vascular access device.
a. 1, 3, 2, 7, 5, 4, 6
b. 1, 3, 2, 5, 7, 6, 4
c. 3, 2, 1, 5, 7, 6, 4
d. 3, 2, 4, 1, 5, 7, 6
```
ANS: D
The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release
tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure
52
```
The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant
in the blood?a. Sodium
b. Chloride
c. Potassium
d. Magnesium
```
ANS: A
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation.
Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is
found predominantly inside cells and in bone
53
```
The nurse receives the patient’s most recent blood work results. Which laboratory value isof
greatest concern?
a. Sodium of 145 mEq/L
b. Calcium of 15.5 mg/dL
c. Potassium of 3.5 mEq/L
d. Chloride of 100 mEq/L
```
ANS: BNormal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and
of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145
mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L
54
```
The nurse observes that the patient’s calcium is elevated. When checking the phosphate level,what
does the nurse expect to see?
a. Increased
b. Decreased
c. Equal to calcium
d. No change in phosphate
```
ANS: B
Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is
elevated, the other decreases, except in some patients with end-stage renal disease
55
Four patients arrive at the emergency department at the same time. Which patient will the nurse
see first?
a. An infant with temperature of 102.2° F and diarrhea for 3 daysb. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
ANS: A
The infant should be seen first. An infant’s proportion of total body water (70% to 80% total body
weight) is greater than that of children or adults. Infants and young children have greater water needs
and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia
because body water loss is proportionately greater per kilogram of weight. A teenager with excessive
edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older
adult with a blood pressure of 112/60
56
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order
will the nurse perform the steps, starting with the first one?
1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve.
a. 1, 2, 3, 4
b. 2, 3, 4, 1c. 3, 4, 1, 2
d. 4, 1, 2, 3
ANS: A
Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove
a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient’s
privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV
solution container from its stand, and pass it and the tubing through the sleeve. (If this involves
removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental
infusion of a large volume of solution or medication.
57
A 2-year-old child is brought into the emergency department after ingesting a medication that
causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor
this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: B
Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and
respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease inCO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting,
diarrhea, or other conditions that affect metabolic acids.
58
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent
suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis
ANS: B
The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung
problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much
acid is in the body like kidney failure
59
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?
a. pH 7.60, PaCO2 40 mm Hg, HCO – 30 mEq/L
b. pH 7.53, PaCO2 30 mm Hg, HCO – 24 mEq/L
c. pH 7.35, PaCO2 35 mm Hg, HCO – 26 mEq/L
d. pH 7.25, PaCO2 48 mm Hg, HCO – 23 mEq/L
ANS: B
Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a
normal HCO –
. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45
mm Hg), and HCO – is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO –
30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO – 26 mEq/L is within normal
limits. pH 7.25, PaCO2 48 mm Hg, HCO – 23 mEq/L is respiratory acidosis
60
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia.
Which assessment finding will the nurse expect?
a. Dry mucous membranes
b. Abdominal distention
c. Distended neck veins
d. Flushed skin
ANS: B
Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel
sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral
pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration
and hypernatremia
61
In which patient will the nurse expect to see a positive Chvostek sign?
a. A 7-year-old child admitted for severe burns
b. A 24-year-old adult admitted for chronic alcohol abuse
c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism
d. A 75-year-old patient admitted for a broken hip related to osteoporosis
ANS: B
A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia
is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis
(which also can be affected by alcohol consumption). Burn patients frequently experience
extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is
associated with hypercalcemia
62
```
A patient is experiencing respiratory acidosis. Which organ system is responsible for
compensation in this patient?
a. Renal
b. Endocrine
c. Respiratory
d. Gastrointestinal
```
ANS: A
The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the
respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate.
Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these
systems cannot compensate for an existing imbalance.
63
.A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse
assign to the nursing assistive personnel?
a. Recording intake and output
b. Regulating intravenous flow rate
c. Starting peripheral intravenous therapy
d. Changing a peripheral intravenous dressing
ANS: A
A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating
flow rate, starting an IV, or changing an IV dressing to an NAP
64
. The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which
laboratory findings are consistent with metabolic acidosis?
a. pH 7.3, PaCO2 36 mm Hg, HCO – 19 mEq/L
b. pH 7.5, PaCO2 35 mm Hg, HCO – 35 mEq/L
c. pH 7.32, PaCO2 47 mm Hg, HCO – 23 mEq/L
d. pH 7.35, PaCO2 40 mm Hg, HCO – 25 mEq/L
ANS: A
The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO – 19 mEq/L.
A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO – 35 mEq/L is metabolic alkalosis. pH 7.32,
PaCO2 47 mm Hg, HCO – 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO – 25
mEq/L values are within normal range
65
```
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention.
Which action will the nurse take first?
a. Offer calcium-rich foods.
b. Administer diuretic.
c. Raise head of bed.
d. Increase fluids
```
ANS: C
The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action.
Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is
the second action. Increasing fluids is contraindicated and would make the situation worse
66
.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse
is mostappropriate?
a. “Are you following any weight loss program?”
b. “How many calories a day do you consume?”
c. “Do you have dry mouth or feel thirsty?”
d. “How many times a day do you urinate?”
ANS: D
A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with
normal ECV. Asking the patient about urination habits will help determine whether the body is trying
to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a
weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not
help determine the cause of the problem. Caloric intake does not account for rapid weight changes.
Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.
67
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered.
Which IV bag will the nurse prepare?
a. 0.45% sodium chloride (1/2 NS)b. 0.9% sodium chloride (NS)
c. Lactated Ringer’s (LR)
d. Dextrose 5% in Lactated Ringer’s (D5LR)
ANS: A
| 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.
68
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient
and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for
monitoring both of these patients?
a. Assess the patients for edema in extremities.
b. Ask the patients to record their intake and output.
c. Weigh the patients every morning before breakfast.
d. Measure the patients’ blood pressures every 4 hours.
ANS: C
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is
equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time
every day using the same scale and the same amount of clothing. Although intake and output records
are important assessment measures, some patients are not able to keep their own records themselves.
Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical
dehydration
69
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and
elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN)
will the nurse add to the care plan?
a. Stimulate the patient’s appetite to eat.
b. Deliver antibiotics to fight off infection.
c. Replace fluid, electrolytes, and nutrients.
d. Provide medication to raise blood pressure
ANS: C
Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace
the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain
blood pressure medication or antibiotics
70
A patient presents to the emergency department with reports of vomiting and diarrhea for the past
48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse
prepare?a. 0.225% sodium chloride (1/4 NS)
b. 0.45% sodium chloride (1/2 NS)
c. 0.9% sodium chloride (NS)
d. 3% sodium chloride (3% NaCl)
ANS: C
Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace
extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45%
sodium chloride are hypotonic. 3% sodium chloride is hypertonic
71
A nurse is administering a diuretic to a patient and teaching the patient about foods to increase.
Which food choices by the patient will best indicate successful teaching?
a. Milk and cheese
b. Potatoes and fresh fruit
c. Canned soups and vegetables
d. Whole grains and dark green leafy vegetables
ANS: B
Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and
vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium
72
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patientwith
hypernatremia. Which finding indicates goal achievement?
a. Urine output increases to 150 mL/hr.
b. Systolic and diastolic blood pressure decreases.
c. Serum sodium concentration returns to normal.
d. Large amounts of emesis and diarrhea decrease
ANS: C
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an
accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous
therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large
dilute urine output can cause further hypernatremia
73
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice
at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice
chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the
nurse document in the patient’s medical record?
a. Intake 255; output 375b. Intake 285; output 375
c. Intake 505; output 125
d. Intake 535; output 125
ANS: A
Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of
the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and
250 mL of vomitus; 125 + 250 = 375.
74
```
A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for
extracellular fluid volume deficit?
a. Moist mucous membranes
b. Postural hypotension
c. Supple skin turgor
d. Pitting edema
```
ANS: B
Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry
mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining
excess extracellular fluid.
75
.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.
The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute
flow rate (drops/min)?
a. 12 drops/min
b. 24 drops/min
c. 125 drops/min
d. 150 drops/min
ANS: C
Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing:
(125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min
76
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to
infuse at 50 mL/hr. At what time should the infusion be completed?
a. 2300 Monday
b. 2345 Monday
c. 0015 Tuesday
d. 0045 Tuesday
ANS: B
250 mL ÷ 50 mL/hr = 5 hr
1845 + 5 hr = 2345, which would be 2345 on Monday.
77
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the
volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9%
sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice
chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output.
The patient has voided 400 mL of urine. After reporting these values to the health care provider,
which order does the nurse anticipate?
a. Add a potassium supplement to replace loss from output.
b. Decrease the rate of intravenous fluids to 100 mL/hr.
c. Administer a diuretic to prevent fluid volume excess.
d. Discontinue the nasogastric suctioning
ANS: A
The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with
nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium
supplement to correct this condition. Remember to record half the volume of ice chips when
calculating intake. The other measures would be unnecessary because the net fluid volume is equal
78
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the
nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse
notices a red streak that is warm to the touch. What is the nurse’s initial action?
a. Record a phlebitis grade of 4.
b. Assign an infiltration grade.
c. Apply moist compress.
d. Discontinue the IV
ANS: D
The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has
phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued
79
.A nurse is assisting the health care provider in inserting a central line. Which action indicates the
nurse is following the recommended bundle protocol to reduce central line-associated bloodstream
infections (CLABSI)?
a. Preps skin with povidone-iodine solution.
b. Suggests the femoral vein for insertion site.
c. Applies double gloving without hand hygiene.
d. Uses chlorhexidine skin antisepsis prior to insertion
ANS: DA recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of
maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion
and during dressing changes; avoidance of the femoral vein for central venous access for adults; and
daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not
recommended
80
The nurse is caring for a group of patients. Which patient will the nurse see first?
a.
A patient with D5W hanging with the blood
b. A patient with type A blood receiving type O blood
c. A patient with intravenous potassium chloride that is diluted
d. A patient with a right mastectomy and an intravenous site in the left arm
ANS: A
The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to
administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis
or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O.
Type O is considered the universal donor. A patient with a mastectomy should have the IV in the
other arm. Potassium chloride should be diluted, and it is never given IV push
81
```
A nurse is administering a blood transfusion. Which assessment finding will the nurse
report immediately?
a. Blood pressure 110/60
b. Temperature 101.3° F
c. Poor skin turgor and pallor
d. Heart rate of 100 beats/min
```
ANS: B
A fever should be reported immediately and the blood transfusion stopped. All other assessment
findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease
tachycardia
82
```
.A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest
time the nurse can let the blood infuse?
a. 30 minutes
b. 2 hours
c. 4 hours
d. 6 hours
```
ANS: CIdeally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened
to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for
bacterial contamination of the blood
83
.A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing
the blood transfusion, which is the nurse’s next action?
a. Discontinue the IV catheter.
b. Return the blood to the blood bank.
c. Run normal saline through the existing tubing.
d. Start normal saline at TKO rate using new tubing.
ANS: D
The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein
open, in case any medications need to be delivered through an IV site. The existing tubing should not
be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve
the IV catheter in place for IV access to treat the patient. After the patient has been assessed and
stabilized, the blood can be returned to the blood bank
84
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is
anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles inboth lung bases and sees jugular vein distention. On which transfusion complication will the nurse
focus interventions?
a. Fluid volume overload
b. Hemolytic reaction
c. Anaphylactic shock
d. Septicemia
ANS: A
The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have
presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic
reaction would consist of flank pain, chills, and fever
85
A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain?
a. Two-way valves to allow the patient’s blood to mix and warm the blood transfusing
b. An injection port to mix additional electrolytes into the blood
c. A filter to ensure that clots do not enter the patient
d. An air vent to let bubbles into the blood
ANS: CWhen administering a transfusion you need an appropriate-size IV catheter and blood administration
tubing that has a special in-line filter. The patient’s blood should not be mixed with the infusion
blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with
blood is normal saline; no additives should be mixed with the infusing blood
86
```
The nurse is caring for a patient with hyperkalemia. Which body system assessment is
the priority?
a. Gastrointestinal
b. Neurological
c. Respiratory
d. Cardiac
```
ANS: D
Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias
and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority
with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for
other electrolyte imbalances
87
Which assessment finding will the nurse expect for a patient with the following laboratory values:
sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?a. Weak quadriceps muscles
b. Decreased deep tendon reflexes
c. Light-headedness when standing up
d. Tingling of extremities with possible tetany
ANS: D
This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia
causes muscle tetany, positive Chvostek’s sign, and tingling of the extremities. Sodium and
potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0
mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes
hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep
tendon reflexes are related to hypercalcemia or hypermagnesemia
88
While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes
that results from a head injury and does not require insulin. Which dietary change should the nurse
share with the patient?
a. Reduce the quantity of carbohydrates ingested to lower blood sugar.
b. Include a serving of dairy in each meal to elevate calcium levels.
c. Drink plenty of fluids throughout the day to stay hydrated.
d. Avoid food high in acid to avoid metabolic acidosis
ANS: C
The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient.
89
A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the
nurse take? (Select all that apply.)
a. Check for contraindications to the extremity.
b. Start proximally and move distally on the arm.
c. Choose a vein with minimal curvature.
d. Choose the patient’s dominant arm.
e. Select a vein that is rigid.
f. Avoid areas of flexion
ANS: A, C, F
The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV
catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should
be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally
and move proximally, choosing the nondominant arm if possible. The nurse should feel for the bestlocation; a good vein should feel spongy, a rigid vein should be avoided because it might have had
previous trauma or damage
90
Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)
a. Edema of the extremity near the insertion site
b. Reddish streak proximal to the insertion site
c. Skin discolored or pale in appearance
d. Pain and warmth at the insertion site
e. Palpable venous cord
f. Skin cool to the touch
ANS: A, C, F
Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and
may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are
all symptoms of phlebitis
91
.A nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take?
(Select all that apply.)a. Wear sterile gloves and a mask.
b. Stop the infusion before removing the IV catheter.
c. Use scissors to remove the IV site dressing and tape.
d. Apply firm pressure with sterile gauze during removal.
e. Keep the catheter parallel to the skin while removing it.
f. Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, E, F
The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the
patient’s skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein;
and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site.
Scissors should not be used because they may accidentally cut the catheter or tubing or may injure
the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to
prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands
will handle the external dressing, tubing, and tape, which are not sterile
92
A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for
dehydration?
a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired
d. An 83-year-old with congestive heart failure
ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk for development
of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his
or her need for fluids known is at high risk for dehydration.
93
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the
nurse implement first?
a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate
would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly
with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers
position will not address the clients problem.
94
After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching?
a. I must drink a quart of water or other liquid each day. b. I will weigh myself each morning before I eat or drink. c. I will use a salt substitute when making and eating my meals. d. I will not drink liquids after 6 PM so I wont have to get up at night.
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or
fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements
are not indicative of practices that will prevent dehydration.
95
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
ANS: A
ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water
and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.
96
A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being
at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss
include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI
suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at
increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The
other two clients on a fluid restriction and with constipation are not at risk for fluid loss.
97
A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse
correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the clients posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic light-headedness and dizziness
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid
volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and
decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and
increased specific gravity are all manifestations of dehydration.
98
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole wheat crackers
d. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with
sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham,
tomato soup, salami, and crackers are often high in sodium.
99
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first
for potential hyponatremia?
a. A 34-year-old on NPO status who is receiving intravenous D5W
b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by
mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and
digoxin will not put a client at risk for hyponatremia.
100
A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in
this clients teaching?
a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.
ANS: C
Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the
sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they
do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium
content of a meal.
101
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium
1. 8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and
muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients
respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and
depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are
secondary to the clients respiratory status.
102
A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular
changes. Which prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.
ANS: C
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the
extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the
activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and
therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this
therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take
much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium
intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level.
103
ANS: C
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the
extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the
activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and
therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this
therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take
much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium
intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level.
ANS: A
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to
hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
104
A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished
since the previous assessment 1 hour ago. Which action should the nurse take first?
a. Assess the clients respiratory rate, rhythm, and depth. b. Measure the clients pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of
hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is
imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in
immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood
pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care
provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the
client should occur during and after potassium replacement therapy.
105
14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching?
a. Toasted English muffin with butter and blueberry jam, and tea with sugar
b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
ANS: C
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and
some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has
the greatest number of items with higher potassium content.
106
A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant
because of my high potassium level. How should the nurse respond?
a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassiuM
ANS: C
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include
apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include
bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.
107
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin (Calcimar)
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac
dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.
108
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 liter of fluids each shift.
d. Dangle the client on the bedside before ambulating.
ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on
the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly
will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the
diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of
fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if
the client has heart failure or renal insufficiency.
109
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the
nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
ANS: A, B, E
Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.
110
A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
a. A 36-year-old who is malnourished
b. A 42-year-old with uncontrolled diabetes
c. A 50-year-old with hyperparathyroidism
d. A 58-year-old with chronic renal failure
e. A 76-year-old who is prescribed antacids
ANS: A, B, E
Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes
mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids. Hyperparathyroidism
and chronic renal failure are common causes of hyperphosphatemia.
111
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L
e. Blood osmolality of 250 mOsm/L
ANS: B, E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of
water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or
condition that disrupts aldosterone secretion or release increases the clients risk for excessive water loss
(increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine
specific gravity. The client would not be at risk for sodium imbalance
112
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential
complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
a. Electrocardiogram changes
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
ANS: A, D, E
Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The
nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and
skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of
hypokalemia.
113
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical
manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
a. Hypokalemia Flaccid paralysis with respiratory depression
b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
c. Hyponatremia Decreased level of consciousness
d. Hypercalcemia Positive Trousseaus and Chvosteks signs
e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension
ANS: A, C
Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness
is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with
hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with
hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated
with hypermagnesemia.
114
After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which
manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)
ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep
tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not
demonstrate that treatment is working.
115
A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should
the nurse include in this clients care plan? (Select all that apply.)
a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2
ANS: B, D
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a
priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear
nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide
safety for this client.
116
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients
arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which
manifestation should the nurse identify as an example of the clients compensation mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing
off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but
are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
117
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values
are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse
perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation
ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and
cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be
present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should
be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will
change as acidosis worsens.
118
ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and
cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be
present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should
be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will
change as acidosis worsens.
ANS: D
Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss
through the renal system. This situation is an acid deficit of metabolic origin.
119
A nurse is caring for a client who is experiencing moderate metabolic alkalosis, Which action should the nurse take?
a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.
ANS: D
The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client
safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing
interventions are not appropriate for metabolic alkalosis.
120
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which
manifestation of this acid-base imbalance should the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvosteks sign
ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis
through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul
respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the electrolyte imbalances
that accompany alkalosis.
121
A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values
are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take
next?
a. Assess clients rate, rhythm, and depth of respiration. b. Measure the clients pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can
lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these
would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to
monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.
122
A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2
65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that
the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low
oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a
chronic problem, because no renal compensation has occurred.
123
A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial
blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should
the nurse take first?
a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the clients nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
ANS: A
The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal
muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the
fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the clients nose and
mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the clients arterial
bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.
124
After teaching a client who was malnourished and is being discharged, a nurse assesses the clients
understanding. Which statement indicates the client correctly understood teaching to decrease risk for the
development of metabolic acidosis?
a. I will drink at least three glasses of milk each day. b. I will eat three well-balanced meals and a snack daily. c. I will not take pain medication and antihistamines together. d. I will avoid salting my food when cooking or during meals
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to
using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient
calories from all food groups helps reduce this risk.
125
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28
mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema
ANS: B
The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial
pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to
hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory
acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis
126
After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for
metabolic alkalosis. Which statement indicates the client needs additional teaching?
a. I dont drink milk because it gives me gas and diarrhea. b. I have been taking digoxin every day for the last 15 years. c. I take sodium bicarbonate after every meal to prevent heartburn. d. In hot weather, I sweat so much that I drink six glasses of water each day.
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic
alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.
127
A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values
are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the
nurse expect to receive?
a. Furosemide (Lasix) 40 mg intravenous push
b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
c. Mechanical ventilation
d. Indwelling urinary catheter
ANS: B
This clients arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from
diarrhea. The bicarbonate should be replaced to help restore this clients acid-base balance. Furosemide would
cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the clients
pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to
treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator
muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this
client.
128
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm
Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.
ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However,
the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful
129
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH
7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when
developing this clients plan of care?
a. Do you take any over-the-counter medications?
b. You appear anxious. What is causing your distress?
c. Do you have a history of anxiety attacks?
d. You are breathing fast. Is this causing you to feel light-headed?
ANS: B
The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes
of the anxiety. The other questions will not identify the cause of the acid-base imbalance.
130
A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via
nasal cannula. The following clinical data are available:
Arterial Blood Gases Vital Signs
pH = 7.28 Pulse rate = 96 beats/min
PaO2 = 85 mm Hg Blood pressure = 135/45
PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min
HCO3 = 26 mEq/L O2 saturation = 88%
Which action should the nurse take first?
a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowlers position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.
ANS: A
The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen
level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory
arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the clients
respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with
chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a
mask does nothing to improve the clients hypoxic drive, nor would it address the clients most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.
131
A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood remains
within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid- base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
ANS: A, B, E
Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and
enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing
the effectiveness of many drugs.
132
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values
are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical manifestations
should the nurse assess? (Select all that apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate
d. Decreased urinary output
e. Positive Trousseaus sign
ANS: A, B, C
Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the
metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseaus sign is associated
with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.
133
A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with
the acid-base imbalance? (Select all that apply.)
a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain
b. Metabolic acidosis Older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells
e. Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease
ANS: B, C, E
Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially
IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a
strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism
and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume
will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for
bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate
antacids may increase the risk of metabolic alkalosis.
134
A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an
acid-base imbalance should the nurse assess? (Select all that apply.)
a. Positive Chvosteks sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic
alkalosis include positive Chvosteks sign, normal or low blood pressure, increased heart rate, skeletal muscle
weakness, and anxiety and irritability.
135
A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas values are pH
7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions should the nurse ask the
client and spouse when developing the plan of care? (Select all that apply.)
a. Are you taking any antacid medications?
b. Is your spouses current behavior typical?
c. Do you drink any alcoholic beverages?
d. Have you been experiencing any vomiting?
e. Are you experiencing any shortness of breath?
ANS: B, C
This clients symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should
ask the clients spouse or family members if the clients behavior is typical for him or her, and establish a
baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because
alcohol can change a clients personality and cause metabolic acidosis. The other options are not causes of
metabolic acidosis.
136
The student nurse learns that the most important function of inflammation and immunity is which purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
ANS: C
The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the
offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and
regulating self-tolerance.
137
A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best?
a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.
ANS: A
Because older adults have decreased immune function, including reduced neutrophil function, fever may not
be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be
needed depending on the results of further assessment.
138
A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most
important?
a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.
ANS: A
Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds
and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take
medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor
category, such as tacrolimus (Prograf).
139
4. A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
ANS: A
Older adults may have insufficient antibodies that have already been produced against microbes to which they
have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger
people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.
140
```
A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation
does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
```
ANS: B
During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.
141
. A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in
this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
ANS: A
The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These
cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
142
The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural
passive do not last as long. Inflammatory is not a type of immunity.
143
The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
ANS: D
Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct
cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory
action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as
viruses or protozoa.
144
A client has been on dialysis for many years and now is receiving a kidney transplant. The client
experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
a. Dialysis
b. High-dose steroid administration
c. Monoclonal antibody therapy
d. Plasmapheresis
ANS: A
Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is
removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal
antibodies, and plasmapheresis are ineffective against this type of rejection.
145
A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the
most rapid communication with the provider?
a. Blood urea nitrogen (BUN) of 18 mg/dL
b. Cloudy, foul-smelling urine
c. Creatinine of 3.9 mg/dL
d. Urine output of 340 mL/8 hr
ANS: C
A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of
rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a
urinary tract infection.
146
```
The nurse working in an organ transplantation program knows that which individual is typically the best
donor of an organ?
a. Child
b. Identical twins
c. Parent
d. Same-sex sibling
```
ANS: B
The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.
147
An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test
comes back negative. What action by the nurse is best?
a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).
ANS: D
Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB
test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia
vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of
fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a
false negative.
148
A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What
response by the nurse is best?
a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.
ANS: A
Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T
lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes,
resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine
[Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated
lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of
interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection
149
```
For a person to be immunocompetent, which processes need to be functional and interact appropriately with
each other? (Select all that apply.)
a. Antibody-mediated immunity
b. Cell-mediated immunity
c. Inflammation
d. Red blood cells
e. White blood cells
```
ANS: A, B, C
The three processes that need to be functional and interact with each other for a person to be
immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and
white blood cells are not processes.
150
A student nurse is learning about the types of different cells involved in the inflammatory response. Which
principles does the student learn? (Select all that apply.)
a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis
ANS: B, C, D, E
Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of
phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one
episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or
hypersensitivity responses.
151
```
The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include?
(Select all that apply.)
a. Edema
b. Pulselessness
c. Pallor
d. Redness
e. Warmth
```
ANS: A, D, E
| The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
152
Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)
a. Antibody-antigen binding
b. Invasion
c. Opsonization
d. Recognition
e. Sensitization
A, B, D, E
153
The student nurse is learning about the functions of different antibodies. Which principles does the student
learn? (Select all that apply.)
a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.
ANS: A, C, D, E
Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes.
Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the
circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly
sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low
concentrations.
154
```
A nurse is working with a community group promoting healthy aging. What recommendation is best to help
prevent osteoarthritis (OA)?
a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.
```
ANS: C
Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms
once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and
weight-bearing exercise are both important for osteoporosis
155
A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to
treat the disease. For which medication does the nurse plan primary teaching?
a. Acetaminophen (Tylenol)
b. Cyclobenzaprine hydrochloride (Flexeril)
c. Hyaluronate (Hyalgan)
d. Ibuprofen (Motrin)
ANS: A
All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is
a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a
nonsteroidal anti-inflammatory drug.
156
The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most
appropriate?
a. Are you compliant with following the diabetic diet?
b. Have you been taking glucosamine supplements?
c. How much exercise do you really get each week?
d. Youre still taking your diabetic medication, right?
ANS: B
All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should
ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking
how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is
patronizing.
157
The nurse working in the orthopedic clinic knows that a client with which factor has an absolute
contraindication for having a total joint replacement?
a. Needs multiple dental fillings
b. Over age 85
c. Severe osteoporosis
d. Urinary tract infection
ANS: C
Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the
new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.
158
An older client has returned to the surgical unit after a total hip replacement. The client is confused and
restless. What intervention by the nurse is most important to prevent injury?
a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the clients hands. d. Use an abduction pillow.
ANS: D
Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or
restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow
since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should
be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this
situation.
159
. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a
client having a total joint replacement?
a. Administer preoperative antibiotic as ordered. b. Assess the clients white blood cell count. c. Instruct the client to shower the night before. d. Monitor the clients temperature postoperatively
ANS: A
To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply
taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The
other options are processes to monitor for infection, not prevent it.
160
The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients
surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the
surgeon, what action by the nurse is best?
a. Assess neurovascular status in both legs.
b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.
ANS: A
This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can
cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The
nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if
possible, but first the nurse should thoroughly assess the client.
161
A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes
b. Change the settings based on range of motion
c. Raise the lower siderail on the affected side
D. Remind the client to do quad-setting exercises
ANS: C
Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and
new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from
occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained
technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.
162
After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve
blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse
perform next?
a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the clients bladder or perform a bladder scan
ANS: C
With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since
this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider
immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.
163
A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action
by the nurse is most important?
a. Administering pain medication before transport
b. Answering any last-minute questions by the client
c. Ensuring the family has directions to the facility.
d. Providing a verbal hand-off report to the facility
ANS: D
As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the
new provider to prevent error. The other options are valid responses but do not take priority.
164
A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client
should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
ANS: B
All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.
165
12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from
surgery. What action by the nurse is best?
a. Assist the client to change positions. b. Document the findings in the clients chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.
ANS: D
Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the
phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal
cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion
may actually worsen the situation. The nurse should document findings after notifying the provider.
166
13. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What
assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome?
a. Abdominal assessment
b. Oxygen saturation
c. Renal function studies
d. Visual acuity
ANS: D
Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in
females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.
167
The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority
problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are
being met?
a. Attends meetings of a book club
b. Has a positive outlook on life
c. Takes medication as directed
d. Uses assistive devices to protect joints
ANS: A
All of the activities are appropriate for a client with RA. Clients who have a poor body image are often
reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem
are being met.
168
15. A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?
a. Giving subcutaneous injections
b. Having a chest x-ray once a year
c. Taking the medication with food
d. Using heat on the injection site
ANS: A
Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self- administer the medication. The other options are not appropriate for etanercept.
169
The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client
should the nurse see first?
a. Client taking celecoxib (Celebrex) and ranitidine (Zantac)
b. Client taking etanercept (Enbrel) with a red injection site
c. Client with a blood glucose of 190 mg/dL who is taking steroids
d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
ANS: D
Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections,
tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept
injections. Steroids are known to raise blood glucose levels.
170
A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What
nonpharmacologic treatment does the nurse apply?
a. Heating pad
b. Ice packs
c. Splints
d. Wax dip
ANS: B
Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.
171
The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute
exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to
assess the client further?
a. Creatinine: 3.9 mg/dL
b. Platelet count: 210,000/mm3
c. Red blood cell count: 5.2/mm3
d. White blood cell count: 4400/mm3
ANS: A
Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the
nurse needs to perform further assessments related to this finding. The other laboratory values are normal.
172
A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain
with ambulation. Which action by the nurse is best?
a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.
ANS: A
Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should
determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough
information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying
the provider immediately is not warranted.
173
. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute
exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another
hospitalization disrupting the family. What action by the nurse is best?
a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.
ANS: B
SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the
family. Helping the client make backup plans for this event not only will decrease the disruption but will give
the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to
problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention
as helping the client plan for such events.
174
A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients
ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other
consultation should the nurse facilitate?
a. Dentist
b. Massage therapist
c. Occupational therapy
d. Physical therapy
ANS: A
With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client
to see a dentist. The other referrals are not related to the mouth.
175
he nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?
a. Drink 1 to 2 liters of water each day. b. Have 10 to 12 ounces of juice a day. c. Liver is a good source of iron. d. Never eat hard cheeses or sardines
ANS: A
Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from
occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this
recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.
176
A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What
information is most important to include?
a. Avoid large crowds or people who are ill. b. Stay upright for 1 hour after taking this drug. c. This drug may cause your hair to fall out. d. You may double the dose if pain is severe.
ANS: A
This drug has a Food and Drug Administration black box warning about opportunistic or other serious
infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain
to golimumab.
177
Rheumatoid arthritis and osteoarthritis
Find question and repost. Know differences.
ANS: A
Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid
arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and
Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling
the client that the symptoms will fade with weather changes is not accurate.
178
A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to
prevent wound infection?
a. Assess the clients white blood cell count. b. Culture any drainage from the wound. c. Monitor the clients temperature every 4 hours. d. Use aseptic technique for dressing changes.
ANS: D
Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to
change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of
an infection that is already present.
179
A nurse is discharging a client after a total hip replacement. What statement by the client indicates good
potential for self-management?
a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I wont wash my incision to keep it dry
ANS: C
There are many precautions clients need to take after hip replacement surgery, including not bending more
than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision
daily and patting it dry.
180
The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some
tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?
a. Checking to see if the machine is working
b. Keeping controls in a secure place on the bed
c. Placing padding in the machine per request
d. Storing the CPM machine under the bed after removal
ANS: D
For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other
actions are appropriate.
181
A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?
a. I always wear long sleeves, pants, and a hat when outdoors. b. I try not to use cosmetics that contain any type of sunblock. c. Since I tend to sweat a lot, I use a lot of baby powder. d. Since I cant be exposed to the sun, I have been using a tanning bed
ANS: A
Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds
182
A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and
the surgeon states the client may need a blood transfusion during or after the surgery. What action by the
preoperative nurse is most important?
a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.
ANS: B
The preoperative nurse should ensure that all valid consents are on the chart, including one for blood
transfusions if this may be needed. Administering preoperative medications is important for all preoperative
clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.
183
ANS: B
The preoperative nurse should ensure that all valid consents are on the chart, including one for blood
transfusions if this may be needed. Administering preoperative medications is important for all preoperative
clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.
ANS: B
This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to
increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This
colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is
normal, so avoiding infection is not the priority.
184
A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What
action by the nurse is most important?
a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the clients leg.
ANS: A
The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there
is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the
leg greater than 90 degrees is not allowed.
185
32. A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic
and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?
a. A little sedation will help you get some rest. b. Depression often accompanies fibromyalgia. c. This drug works in the brain to decrease pain. d. You will have more energy after taking this drug.
ANS: C
Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces
the pain from fibromyalgia. The other answers are inaccurate.
186
A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and
worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The
elder is expected to attend social events and make community decisions. Stress seems to exacerbate the
condition. What action by the nurse is best?
a. Assess the clients culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.
ANS: A
The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the
ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any
possible solutions. If the nurse does not understand the consequences of what is suggested, the client may
simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending
on the outcome of a better cultural understanding
187
A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
a. Lets ask the provider about increasing your pain pills. b. Hold ice bags against your hands before quilting. c. Try a paraffin wax dip 20 minutes before you quilt. d. You need to stop quilting before it destroys your fingers.
ANS: C
Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse
can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless
the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate
its importance by telling the client it is destroying her joints.
188
. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most
important?
a. Be sure you get enough sleep at night. b. Eat plenty of high-protein, high-iron foods. c. Notify your provider at once if you get a fever. d. Weigh yourself every day on the same scale.
ANS: C
Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important
but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily
weights may or may not be important depending on renal involvement.
189
A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to
assess the client for Heberdens nodules. What assessment technique is correct?
a. Inspect the clients distal finger joints. b. Palpate the clients abdomen for tenderness. c. Palpate the clients upper body lymph nodes. d. Perform range of motion on the clients wrists
ANS: A
Herberdens nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To
assess for this finding, the nurse inspects the clients distal fingertips. These nodules are not found in the
abdomen, lymph nodes, or wrists.
190
A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement,
the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests
the celecoxib in addition to the morphine. What action by the nurse is best?
a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.
ANS: A
Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on
other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help
with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the
client is in the hospital. The other responses are not warranted, as the client should be restarted on this
medication postoperatively.
191
The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that
apply. )
a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.
ANS: B, C
RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints
and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.
192
A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX)
(Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)
a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. c. Pregnancy and breast-feeding are not affected by MTX. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.
ANS: A, B, D, E
MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver
toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6
weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while
on this drug.
193
```
A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed
medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select
all that apply.)
a. Acupuncture
b. Stretching
c. Supplements
d. Tai chi
e. Vigorous aerobics
```
ANS: A, B, D
There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including
acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress
management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.
194
The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late
manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)
a. Anorexia
b. Feltys syndrome
c. Joint deformity
d. Low-grade fever
e. Weight loss
ANS: B, C, E
Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in
the course of the disease.
195
An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply an abduction pillow to the clients legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.
ANS: A, C, E
The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing
skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility
196
The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired
with their manifestations? (Select all that apply.)
a. Dry, scaly skin rash Systemic lupus erythematosus (SLE)
b. Esophageal dysmotility Systemic sclerosis
c. Excess uric acid excretion Gout
d. Footdrop and paresthesias Osteoarthritis
e. Vasculitis causing organ damage Rheumatoid arthritis
ANS: A, B, E
A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to
esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by
hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and
paresthesias occur in rheumatoid arthritis.
197
A nurse works with several clients who have gout. Which types of gout and their drug treatments are
correctly matched? (Select all that apply.)
a. Allopurinol (Zyloprim) Acute gout
b. Colchicine (Colcrys) Acute gout
c. Febuxostat (Uloric) Chronic gout
d. Indomethacin (Indocin) Acute gout
e. Probenecid (Benemid) Chronic gout
ANS: B, C, D, E
Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and
probenecid. Allopurinol is used for chronic gout.
198
. The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate
to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating
ANS: C, D, E
The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynauds
phenomenon. The UAP can adjust the room temperature for the clients comfort. Keeping the sheets off the feet
will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of
esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can
remind the client of this once he or she has been taught. The other actions are performed by the registered
nurse
199
```
A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options
can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all
that apply.)
a. Grab bars to reach high items
b. Long-handled bath scrub brush
c. Soft rocker-recliner chair
d. Toothbrush with built-up handle
e. Wheelchair cushion for comfort
```
ANS: A, B, D
Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for
daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner
and wheelchair cushion are comfort measures but do not help increase independence.
200
A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on
partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client?
(Select all that apply.)
a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower
ANS: A, B, D, E
Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower
chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step
into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the
hip more than the allowed 90 degrees.
201
A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is
always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)
a. Allow the client uninterrupted rest time. b. Assess the clients usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping
ANS: A, B, C, D
Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and
unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime
routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The
client does not need a strong sleeping pill unless all other options fail and the client requests something for
sleep. At that point a mild sleeping agent can be tried.
202
A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all
that apply.)
a. Elevated antinuclear antibody (ANA) Normal value; no connective tissue disease
b. Elevated sedimentation rate Rheumatoid arthritis
c. Lowered albumin Indicative only of nutritional deficit
d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis
e. Positive rheumatoid factor Possible kidney disease
ANS: D, E
The HLA-B27 is diagnostic for Reiters syndrome or ankylosing spondylitis. A positive rheumatoid factor can
be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of
inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated
sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.
