MEDICAL AS NRSG 1136 Adult Health - Saunders Review Questions and Answer and Rationale,100% CORRECT

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MEDICAL AS NRSG 1136 Adult Health - Saunders Review Questions and Answer and Rationale After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying positi... on. The nurse understands that the purpose of this intervention is to accomplish which? Limit bleeding from the biopsy site Rationale: After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. The liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not the purpose of the right side-lying position. The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? High-Fowler's position Rationale: Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration. The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach? Placement is verified on x-ray. Rationale: The end of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach. Auscultation of the air injection is not recommended as a reliable method to establish correct placement. A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions should be included in the procedure? Select all that apply. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose. Rationale: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube. An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank. Correct Answer: 36 % Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. 3. It is highly metastatic. 5. Lesion is a nevus that has changed in color. Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis. The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. An irregularly shaped lesion Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? "I need to avoid sun exposure before 10:00 am and after 4:00 pm." Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10:00 am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions. A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? A white color of the skin which is insensitive to touch Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days. The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? Partial-thickness skin loss of the epidermis Rationale: With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4. The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? Silvery-white scaly lesions Rationale: Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk. Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? The return of distal pulses Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema. The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? Elevation above the level of the heart Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edem The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? Positive culture results Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious. Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 am to 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced. The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason? Treat hypocalcemic tetany. Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy. The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate? Reassure the client that this is usually a temporary condition. Rationale: Weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate. The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? Apply a moisturizing lotion to dry feet, but not between the toes. Rationale: The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap. The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching? "I need to buy special dietetic foods." Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet, but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods. A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge? Rotate the insulin injection sites systematically. Rationale: Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption. / Shakiness Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia. When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? "I will notify my primary health care provider if my blood glucose level is consistently greater than 250." Rationale: During illness, the client should monitor the blood glucose level, and he or she should notify the PHCP if the level is greater than 250. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice. The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification? "I am urinating a lot." Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia. The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? Monitor blood glucose level frequently. Rationale: Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the PHCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed. The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? "I can eat foods that contain potassium." Rationale: A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue. The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply. 1. Dry skin 5. Constipation 6. Cold intolerance Rationale: Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism. The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention? Laryngeal stridor Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high- pitched sound heard during inspiration and expiration that is caused by the compression of the trachea and leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway. The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection? Plan for injection rotation Rationale: Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise? "I should not exercise in the late afternoon." Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks between 6 and 14 hours; therefore, late-afternoon exercise would occur during the peak of the medication. The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? The medication is withheld and the PHCP is called to question the prescription for the client. Rationale: Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the PHCP regarding this prescription. Although options 1 and 3 are correct statements about the medication, in this situation it should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? Vitamin B12 Rationale: Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 2, and 3 are incorrect. The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify? Irrigating the NG tube Rationale: In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the PHCP. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include during client teaching to help prevent dumping syndrome? Limit the fluids taken with meals. Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? Sweating and pallor Rationale: Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? Diarrhea Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four or five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease. The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply. 1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. Rationale: The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions. It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? Hepatitis A Rationale: HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids. The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart? Supine and flat client positioning Rationale: The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis. A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? Lying recumbent after meals Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? Protruding and swollen Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed. A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client should take which action to monitor the effectiveness of treatment? Checking the frequency and consistency of bowel movements Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? Stay with the person and encourage the person to remain still. Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? Immobilize the leg before moving the client. Rationale: When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? Provides comfort by reducing muscle spasms and provides fracture immobilization Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? Serous drainage Rationale: A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? Check the client's alignment in bed. Rationale: A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? Performing active range of motion (ROM) to the right ankle and knee Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? Presence of a "hot spot" on the cast Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The PHCP should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? Impaired tissue perfusion Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? Elevate the leg on pillows continuously for 24 to 48 hours. Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. Therefore, the other options are incorrect. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? Petaling the cast edges with adhesive tape Rationale: The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The PHCP is notified immediately if circulatory impairment occurs. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 8 inches to the front and side of the client's toes Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance. The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? Moves the cane when the right leg is moved Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support, while the stronger side swings through. The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? Elevating the limb and applying ice to the affected leg Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect. A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? "I need to avoid getting the cast wet." Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching. Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? Evaluate absorption of the last feeding. Rationale: All the stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the PHCP's prescription and agency policy are checked to determine the course of action (hold or reduce the volume of the intermittent tube feeding). The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's syndrome. Which statement by the student indicates an accurate understanding of this disorder? "Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones." Rationale: Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones. Options 1 and 4 are inaccurate regarding Cushing's syndrome. The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. 2. Applying prescribed topical antibiotic 3. Administering prescribed corticosteroid 5. Applying Domeboro solution to the affected skin Rationale: Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. Acyclovir is an antiviral medications used to treat chickenpox or shingles. Amphotericin B is an antifungal used to treat fungal infections. A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? "The exact cause of acne is not known." Rationale: The exact cause of acne is unknown. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Oily skin alone is not the cause of acne. Heat, humidity, and excessive perspiration also play a role in exacerbation of acne. There is no evidence that consumption of foods such as chocolate, nuts, or fatty foods affects acne. A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include? Take a blood glucose test before exercising. Rationale: A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed. The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? Use diluted mouthwash and water to swab the mouth after brushing teeth. Rationale: After the nasogastric tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth breathe, drying the mucous membranes. Frequent oral hygiene may be required to prevent or care for dry, irritated mucous membranes. Frequent, small sips of water would be contraindicated when the client is on gastric suction. The hard candy would increase the salivation but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying or irritating effect on the mucous membranes. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement? "I need to scrub the skin vigorously with soap and water." Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid direct exposure of the skin to the sunlight. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? Left heel Rationale: Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? Slightly elevating the foot of the bed Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. Option 1 places undue pressure on the client's unaffected foot. Option 2 is not used for the purpose of countertraction. Buck's extension traction is applied to the leg, so you can eliminate option 4. The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods. 6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur. Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? Characteristic of a thrush infection Rationale: Candidiasis is a fungal infection caused by Candida albicans. When it occurs in the mouth, it is called thrush and appears as white plaques. Although it can occur in an immunocompromised client, it is not considered to be common. Options 2 and 4 are not accurate regarding this infection. The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? Elevating and immobilizing the affected leg Rationale: Autografts placed over joints or on the lower extremities are often elevated and immobilized after surgery for 3 to 7 days. This period of immobilization allows time for the autograft to adhere and attach to the wound bed. The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching? "I should never wear warm clothing over the newly healed skin area." Rationale: Newly healed skin is more sensitive to the cold, and the client should be instructed to wear warm clothing. The client should wash with a mild soap, rinse thoroughly, and pat the skin dry with a clean towel. Newly healed skin sunburns easily, and direct sunlight needs to be avoided. Products that contain perfume, alcohol, or lanolin should be avoided because they tend to irritate newly healed skin. The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder? An outdoor construction worker Rationale: Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. An older client may be at a higher risk than a younger individual because immobility and lack of nutrition may increase the older person's risk. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. The physical education teacher is at low or no risk of developing an integumentary problem. The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching? "I will remove the dressing when I get home and wash the site with tap water." Rationale: After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy. The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure? Darken the room for the examination. Rationale: The examination of the skin under a Wood's light is always carried out in a darkened room. This is a noninvasive examination; therefore, informed consent is not required. A hand-held, long- wavelength ultraviolet light or Wood's light is used. The skin does not need to be shaved, and a local anesthetic is not necessary. Areas of blue-green or red fluorescence are associated with certain skin infections. The procedure is painless. The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching? "I should use a dehumidifier, especially during the winter months." Rationale: The client should avoid using a dehumidifier because this will further dry the room air. Instead, the client should use a room humidifier during the winter months or whenever the furnace is in use. The client should be taught to maintain a daily fluid intake of 3000 mL, unless contraindicated, and to avoid alcohol and caffeine. The client should avoid applying rubbing alcohol, astringents, or other drying agents to the skin. One bath or shower per day for 15 to 20 minutes with warm water and a mild soap would be immediately followed by the application of an emollient to prevent the evaporation of water from the hydrated epidermis. A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? "Take a shower immediately, and lather and rinse several times." Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the skin. The client should be instructed to shower immediately, to lather the skin several times, and to rinse each time in running water. Calamine lotion is a treatment that is used when dermatitis develops. It is not necessary for the client to be seen in the emergency department at this time. A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question? "It is a skin infection that involves the deeper skin layers and subcutaneous fat." Rationale: Cellulitis is a skin infection into the deeper dermis and the subcutaneous fat, usually caused by Streptococcus pyogenes; it results in deep red erythema without sharp borders, and it spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and the lymphatics. The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client? Warm compresses to the affected area Rationale: Warm compresses may be used to decrease discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. Heat lamps can cause more disruption to tissue that is already inflamed. Continuous cold and hot compresses are not the best measures. The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment? Culture of the lesion Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the cause of chickenpox. A viral culture of the lesion provides the definitive diagnosis. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy will determine tissue type. During a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. Which client complaint should alert the nurse to a possible hypoglycemic reaction? Tremors and double vision Rationale: Decreased blood glucose levels produce automatic nervous system symptoms, which are classically manifested as nervousness, irritability, and tremors. Hot, dry skin is more likely to occur with hyperglycemia. Anorexia, muscle cramps, and elevated temperature are unrelated to the signs of hypoglycemia. Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? Monitor the client's blood pressure. Rationale: Hypertension is the major symptom that is associated with pheochromocytoma. The blood pressure status is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are also signs/symptoms of pheochromocytoma, but hypertension is the major symptom. The nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action should be to monitor which criterion? Vital signs Rationale: Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure. The nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which is the appropriate choice for this client to meet nutritional needs? Graham crackers and warm milk Rationale: The client with pheochromocytoma needs to be provided with a diet that is high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited. The nurse is caring for a client with pheochromocytoma. Which data are indicative of a potential complication associated with this disorder? Congestion heard on auscultation of the lungs Rationale: The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, heart failure (HF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of heart failure (HF). A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding. The nurse is caring for a client after a thyroidectomy and monitoring for signs of thyroid storm. The nurse determines that which sign/symptom is indicative that a thyroid storm may be occurring? Blood pressure of 80/60 mm Hg Rationale: Signs/symptoms associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse. When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is essential? Test the drainage for glucose. Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which signs/symptoms are indicative of this disorder? Excessive thirst and urine output Rationale: Excessive thirst (polydipsia) and excessive urine output (polyuria) are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea and blurred vision are not manifestations of the disorder. Weight gain and increased urine specific gravity are associated with syndrome of inappropriate antidiuretic hormone (SIADH). Which signs/symptoms should the nurse expect to note when collecting data on a client with Addison's disease? Hypotension and vomiting Rationale: Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea, vomiting, abdominal cramps, weight loss, depression, and irritability. The manifestations in the remaining options are not associated with Addison's disease. Which measure should the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? A restful environment Rationale: Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment. The client diagnosed with acute pancreatitis is experiencing severe pain from the disorder. The nurse should instruct the client to avoid which position that could aggravate the pain? Lying flat Rationale: Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions. The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet? Turkey and lettuce sandwich Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Red meats (hamburger and steak) contain fat. Mashed potatoes are usually made with milk and butter. The correct food item that is low in fat is the turkey and lettuce sandwich. A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom should the nurse expect to observe based on this diagnosis? Fatigue Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver. Which infection control method should the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? Hepatitis B vaccine Rationale: Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin may be used to prevent hepatitis A and is used for prophylaxis if the client is traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A. The client admitted to the hospital with a diagnosis of viral hepatitis is complaining of a loss of appetite. In order to provide adequate nutrition, which action should the nurse encourage the client to take? Increase intake of fluids. Rationale: Although no special diet is required in the treatment of viral hepatitis, it is generally recommended that clients have a diet with low-fat content because fat may be poorly tolerated due to decreased bile production. Small frequent meals are preferable and may even prevent nausea. Often times, the appetite is better in the morning, so it is easier to eat a healthy breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional fluids is also important. The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus? Inability to pass flatus Rationale: An inflammatory reaction, such as acute pancreatitis, can cause paralytic ileus the most common form of nonmechanical obstruction. Inability to pass flatus is a sign/symptom of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, nontender mass palpable at the lower right costal margin describes the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, it is not a sign of paralytic ileus or intestinal obstruction. A client with a diagnosis of viral hepatitis has no appetite, and food makes the client nauseated. The nurse should conclude that which intervention is most appropriate? Offer small, frequent meals. Rationale: If nausea persists, the client will need to be assessed for fluid and electrolyte imbalances. It is important to explain to the client that the majority of calories should be eaten in the morning hours because nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated. The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse should include which risk factor for colorectal cancer in the material? Personal history of ulcerative colitis or gastrointestinal (GI) polyps Rationale: Common risk factors for colorectal cancer include age over 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems such as ulcerative colitis or familial polyposis. A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place highest priority on which action as part of the client's care plan? Checking for return of a gag reflex Rationale: The nurse places highest priority on managing the client's airway. This includes assessing for return of the gag reflex. The client's vital signs are also monitored and a sudden sharp increase in temperature could indicate perforation of the gastrointestinal (GI) tract. This should be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway still takes priority. The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below- knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply. 2. Bony deformity 3. Limited joint mobility 4. Peripheral neuropathy 5. Peripheral vascular disease 6. History of skin ulcers or previous amputation Rationale: Certain conditions place clients with diabetes at increased risk for amputation. These factors include peripheral neuropathy, limited joint mobility, bony deformity, peripheral vascular disease, and a history of skin ulcers or previous amputation. The nurse needs to observe for changes that indicate peripheral neuropathy or vascular insufficiency. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? "It is a normal response and indicates the presence of phantom limb sensation." Rationale: Phantom limb sensations felt in the area of the amputated limb indicate a normal response. These can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, called "phantom limb pain." The origin of the pain is less well understood, but the client should also be prepared for this whenever possible. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which action should be done? Get out of bed by sitting straight up and swinging the legs over the side of the bed. Rationale: The client needs further teaching if the client says sitting straight up and swinging the legs over the side is the way to get out of bed. Clients are taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed, using one or both arms. The back is kept straight, and the legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects. A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? Notify the registered nurse. Rationale: The client with pallor, slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. Regardless of the cause, the LPN notifies the registered nurse immediately, who will contact the primary health care provider. These signs can occur with constriction from a tight cast as well. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area. A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? A window will be cut in the cast. Rationale: A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking x-rays, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated. A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? High-calcium diet consumption Rationale: The nursing student needs further teaching if the student states that a high-calcium diet is an associated risk factor of osteoporosis. Risk factors associated with osteoporosis include a diet that is deficient in calcium. Postmenopausal age, family history, and long-term use of corticosteroids are risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? Pork Rationale: Of the items listed, pork would contain the least amount of calcium. The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? Dull aching pain in the affected joints Rationale: The sign/symptom associated with osteoarthritis is dull, aching pain that occurs in the affected joints. Unlike rheumatoid arthritis, systemic manifestations are absent and joint involvement is not symmetrical. The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify after activity, and they may be aggravated by cold, damp weather. No specific laboratory findings are useful in diagnosing osteoarthritis. Morning stiffness, an elevated sedimentation rate, and a positive rheumatoid factor occur in rheumatoid arthritis. A client is treated in the primary health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? Applying a heating pad Rationale: Heat is not used in the first 24 hours after a sprained ankle because it could increase venous congestion, which would increase edema and pain. Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement? "I'll report fever or site inflammation to the primary health care provider." Rationale: The client understands the discharge instructions after a knee arthroscopy if the client plans to report any fever or site inflammation to the primary health care provider. Any signs/symptoms of infection must be reported to the primary health care provider. After arthroscopy the client can usually walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client should the nurse recognize as best supporting the diagnosis of gastric ulcer? "My pain comes shortly after I eat, maybe a half hour or so later." Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half hour to an hour after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night. A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? Low fiber Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea. The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply. 2. Ensure the client doesn't sit or stand for long periods of time. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living. Rationale: The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend his/her hips beyond 90 degrees and not 120 degrees, doesn't sit or stand for long periods of time, and doesn't cross his/her legs past the midline of the body. The nurse should ensure that the client engages in walking and mild, not rigorous, exercise to maintain strength and that the client uses assistive/adaptive devices when performing activities of daily living. A client has a diagnosis of asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? High-fiber diet Rationale: A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume. The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client? High-sodium, high-carbohydrate diet Rationale: A high-sodium, high–complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather; before strenuous exercise; and in response to fever, vomiting, or diarrhea. A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? "The local anesthetic may cause a burning or stinging sensation." Rationale: Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Options 1, 3, and 4 are incorrect. The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information? Palms of the hands Rationale: In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge. he nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching? "If the patch comes off, I need to reapply it." Rationale: The nurse instructs the client to keep the test site dry at all times. The nurse also discourages excessive physical activity that will result in sweating. Reapplying the patch can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later. The nurse prepares to assist in instructing a client about Lyme disease. Which should the nurse include in the instructions? It is caused by a tick carried by deer. Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another. The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2? Neurological deficits Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate? Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. Rationale: There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 3 are incorrect. A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should expect which assessment finding? Appearance of reddish-blue lesions on the lower extremities Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They also can spread to the lymphatic system, lungs, and gastrointestinal (GI) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions. Which individual is least likely to be at risk for the development of Kaposi's sarcoma? An individual working in an environment in which exposure to asbestos is possible Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder. It is a common acquired immunodeficiency syndrome (AIDS) indicator. Malignancy is seen most frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma but could be related to mesothelioma. The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection? Red, shiny skin around the nail bed Rationale: Paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often these become secondarily infected with bacteria or fungus, which later involves the nail. Options 2, 3, and 4 are incorrect descriptions of this disorder. The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs Rationale: Frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite. The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? A client with a lowered mental awareness status Rationale: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and a lowered mental awareness can contribute to the development of skin breakdown. However, the least likely risk as presented in the options is the lowered mental awareness status. Options 1, 2, and 4 identify physiological conditions, which are the highest risk priorities A client is undergoing radiation therapy to treat lung cancer. Which instructions should the nurse reinforce to the client with regard to skin care? Select all that apply. 3. Do not remove any of the markings for radiation treatment. 4. Use the hand to wash the affected area rather than a washcloth. 5. Shower or wash the area once a day using warm water and mild soap. Rationale: Skin care during radiation therapy includes not removing markings, showering or washing the area once a day using warm water and mild soap, and using the hand to wash the affected area rather than a washcloth. The skin should not be subjected to cold and lotions should not be used unless recommended by the radiologist. The nurse is providing care for a client suspected of having appendicitis. Which priority intervention should the nurse anticipate will be prescribed for this client? No oral intake of liquids or food Rationale: For the client with suspected or known appendicitis, the nurse should ensure the client remains on nothing by mouth status in anticipation of emergency surgery and also to avoid worsening the inflammation. Options 1, 2, and 3 are not prescribed for the client with suspected appendicitis. Sodium hypochlorite is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan? Ensure that the solution is freshly prepared before use. Rationale: Sodium hypochlorite solution is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. Solutions are unstable, and the nurse must ensure that the solution has been prepared fresh before use. The nurse is assisting in caring for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury? Leakage of clear fluid from the nose Rationale: When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture. Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? "I will apply the ointment once a day and cover it with a sterile dressing." Rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing. The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which should the nurse include in the instructions? Select all that apply. 2. Use moisturizers and sunscreens. 3. Wash new clothing before it is worn. 4. Use mild detergent and rinse clothes twice. 5. Maintain room temperature at 68° F to 75° F. 6. Wear open-weave fabrics and loose clothing. Rationale: Measures that decrease itching and moisturize the skin help maintain skin integrity. Encourage the client to maintain the room temperature at 68° F to 75° F. New clothing should be washed before it is worn. Mild detergent should be used for laundry and clothes should be rinsed twice. Recommend open-weave fabrics and loose clothing. Advise the use of moisturizers and sunscreens. The humidity should be kept at 45% to 55%. The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching? "I'm glad I can still drink as much coffee as I want." Rationale: There is a need for further teaching when a client with osteoporosis says "I'm glad I can still drink as much coffee as I want." The nurse needs to teach clients to avoid excessive alcohol and caffeine consumption and about the need for adequate amounts of calcium and vitamin D for bone remodeling. The nutritional considerations for the treatment of a client with a diagnosis of osteoporosis are the same as those for preventing the disease. The nurse needs to help the client develop a nutritional plan that is most beneficial in maintaining bone health. The plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine. The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? Administering intramuscular opioid analgesics Rationale: Administering intramuscular opioid analgesics to a client following a bone biopsy is an unnecessary action for the nurse. Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising. A client with possible rib fracture has never had a chest x-ray. The nurse should tell the client which statement about the procedure? "It is necessary to remove jewelry and any other metal objects." Rationale: An x-ray is a photographic image of a part of the body on a special film that is used to diagnose a wide variety of conditions. The x-ray itself is painless. Any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area. The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply. 2. Dyspnea 4. Hypoxemia 5. Tachypnea Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop. The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? Anesthesia consent Rationale: The item that is least likely needed before reduction of a fracture in the casting room is an anesthesia consent. Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room. The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? The client may bear weight on the cast in 30 minutes. Rationale: The client needs further teaching about plaster casts if the client plans to bear weight on the cast in 30 minutes. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? "Lift the left arm up over the head." Rationale: The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? Within 20 to 30 minutes of application Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement? "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Rationale: The client needs further teaching if the client states that if the cast gets wet, drying it with a hair dryer turned to the warmest setting is an option. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. Client instructions should include avoidance of walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse should be most useful in trying to provide good skin care to the client? Asking the client to pull up on a trapeze to lift the hips off the bed Rationale: The nursing action that would be most useful if the client in skeletal traction may not turn from side to side is to have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other. A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? Inspecting the skin on the right leg at least once every 8 hours Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the primary health care provider. Skin traction does not involve pin care. The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching? "My crutches must rest up underneath my arm for extra support." Rationale: There is a need for further teaching when the client states that crutches need to rest up underneath the arm. Crutches must not rest underneath the client's arm, because it could cause injury to the nerves of the brachial plexus. Crutches must be measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body. The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? Crutches and the left leg, then advance the right leg Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait. Putting the crutches and the right leg down, then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then right leg and left crutch down describes a two- point gait. The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching? "Crutch tips will not slip, even when wet." Rationale: There is a need for further teaching when the client says that crutch tips won't slip even when wet. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed. The nurse is teaching a client how to walk with a cane. Which information should the nurse include? Select all that apply. 3. The cane should create no more than 30 degrees of flexion of the elbow. 4. The top of the cane should be parallel to the greater trochanter of the femur. 5. A straight leg cane is used if the client only needs minimal support for an affected leg. Rationale: The cane should create no more than 30 degrees of flexion of the elbow, and the top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist. A straight leg cane is sometimes used if the client needs only minimal support for an affected leg. A hemi-cane or quad-cane provides a broader, not narrower, base for the cane and therefore more support. The cane is placed on the unaffected side and not the affected side. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Thick, yellow drainage from the pin sites Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes. A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? Left hand, and 6 inches lateral to the left foot Rationale: The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What should the nurse tell the client to provide greater reassurance? The cane has a flared tip with concentric rings to provide stability. Rationale: A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. The other items about canes are incorrect. The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? Bleeding and swelling cause increased pressure in an area that cannot expand. Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment triggering the signs/symptoms. The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which issues could place the client at increased risk for disturbed thought processes? Select all that apply. 2. Stress from the fracture 3. Eyeglasses left at home 4. Unfamiliar hospital setting 5. Side effects of medications Rationale: Confusion in the older client with hip fracture could result from the eyeglasses being left at home, an unfamiliar hospital setting, stress from the fracture, side effects of medications, concurrent systemic diseases, or cerebral ischemia. Relatives at the bedside would help the client's functional level, and hearing aids enhance the client's interaction with the environment and can reduce disorientation. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? Pillow to keep the right leg abducted during turning Rationale: Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client. The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply. 1. Ensure that the machine is well padded. 2. Assess the client's response to the machine. 5. Turn off the machine while the client is having a meal in bed. 6. Make sure that the joint being moved is properly positioned on the machine. Rationale: While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach. The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting. Rationale: The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint for stability. The surgeon prescribes the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. A client is complaining of low back pain with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? Bending or lifting Rationale: Low back pain with radiation into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing, or lifting the leg straight up while supine (straight leg raise test). The other actions assist in alleviating pain. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which action to maintain client safety after this procedure? Having the client use an overhead trapeze Rationale: Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery. The nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a need for further teaching? "I'll be careful not to lift anything heavier than 20 pounds." Rationale: There is a need for further teaching when the client states that "I'll be careful not to lift anything heavier than 20 pounds." The client should not lift anything heavier than 5 pounds. After conventional open back surgery, the client may have activity restrictions for the first 4 to 6 weeks, such as restricting or limiting driving, limiting daily stair climbing, avoiding bending and twisting at the waist, taking a daily walk, and restricting pushing-and-pulling activities like dog walking. The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? The device is applied before getting out of bed in the morning. Rationale: A back brace or TLSO is individually fitted to the client. The brace is applied in the morning before getting out of bed. The brace should not irritate the skin with proper fitting. The closures should be secure but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin. A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Showing the client the cast cutter and explaining how it works Rationale: The action by the nurse that would be the most helpful is to show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? Concerns about body image Rationale: The client is expressing concerns about body image. The data in the question are unrelated to isolation and inability to tolerate activity. Although the client is unable to physically move about, this is not associated with what the client is upset about. The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply. 1. Femur 2. Skull 3. Tibia 6. Vertebrae Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur. The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a need for further teaching? "This condition is primarily due to my lack of calcium and testosterone." Rationale: There is a need for further teaching when the client says that lack of calcium and testosterone cause osteomalacia. Osteomalacia is caused by a lack of vitamin D. It is the softening of bone tissue characterized by inadequate mineralization of osteoid. Osteoporosis is caused by a lack of calcium and estrogen in women and testosterone in men. The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? Maintaining body weight at or above minimum recommended levels Rationale: Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high- protein diet, and consuming adequate amounts of vitamin D. The other prevention measures are secondary and not primary prevention measures. The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? Select all that apply. 1. Drink plenty of fluids. 2. Avoid taking diuretics. 5. Avoid excessive physical or emotional stress. Rationale: The nurse needs to teach the client to drink plenty of fluids to prevent the formation of urinary stones. Increasing fluid intake helps dilute urine and prevent sediment formation. The client also needs to avoid taking diuretics because this would limit the amount of fluid in the body and would not help prevent sediment formation. Excessive physical or emotional stress can also exacerbate the disease. The nurse needs to teach the client stress-management techniques to help prevent future attacks of gout. A strict low-purine diet is recommended and clients should avoid foods such as organ meats, shellfish, and oily fish with bones (e.g., sardines). Excessive alcohol intake and fatty meats should also be avoided. The nurse needs to also teach the client to determine which foods precipitate acute attacks and try to avoid them. In addition to food and beverage restrictions, clients with gout should avoid all forms of aspirin and diuretics because they may precipitate an attack. Acetaminophen does not have to be avoided. The nurse is caring for a client with osteoporosis who is being discharged with instructions to take calcium with vitamin D. Which instructions should the nurse give the client about taking this medication? Select all that apply. 1. "Take a third of the daily dose at bedtime." 2. "Increase fluid intake, unless medically contraindicated." 3. "Take the medication with 6 to 8 ounces of water to help dissolve it." Rationale: The nurse needs to tell the client to take a third of the daily dose at bedtime because no weight- bearing activity to build bone occurs while sleeping. Fluids should be increased and the medication should be taken with 6 to 8 ounces of water. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus? Clear chest x-ray Rationale: A clear chest x-ray is a favorable indicator that the fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea (unlabored breathing), not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%. A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? Moist, sterile saline dressings Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. The other types of wound care are incorrect. The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? Numbness and tingling in the fingers Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. An elderly client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? Select all that apply. 1.Osteoporosis 2.Foot disorders 3.Bony metastases 6.Changes in cardiac function Rationale: Disease processes like osteoporosis, foot disorders, bony metastases, and changes in cardiac function increase the older adults' risk for hip fracture. A history of carpal tunnel syndrome does not affect the elderly client's risk for hip fracture. Diminished visual acuity is a sensory, physiological change that can occur in the older adult and is not a disease process. A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? The client advances the walker with reciprocal motion. Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation. A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement? Administer an analgesic. Rationale: Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action? Rewrap the residual limb with an elastic compression bandage. Rationale: If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the residual limb with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation. A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason? Muscle spasm in the area of the herniated disk Rationale: The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The other interpretations of the pain are incorrect. The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? In semi-Fowler's position with the knee gatch slightly raised Rationale: Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi- Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the client flat with the knee gatch raised stretches the lower back. The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding? An oral temperature of 101° F orally Rationale: For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs/symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101° F or higher should be reported because it might indicate infection or require that the hardware be removed. The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." Rationale: The client understands the purpose of the therapy and provides an incentive to comply with the exercises when the client states, "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." The statement, I'm doing this, so I can go home soon" may or may not be true and could relate to a number of factors other than use of the right hand. Saying it hurts but things always hurt at my age is an inaccurate statement. Saying the therapist will get mad if I don't do this is incorrect because it indicates imposition of staff values on the client and is suggestive of possible abuse. The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client? Increasingly vigorous and high-impact exercise Rationale: Vigorous or high-impact exercise could be damaging to articulating surfaces within joints and should be avoided by clients with osteoarthritis. The other actions may be helpful in promoting joint mobility. The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement? "I should resume a full activity level within 1 week." Rationale: The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K. The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial- thickness skin loss and the formation of a blister. The nurse should document the pressure injury as which category? Stage II Rationale: A stage II pressure injury is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. A stage I pressure injury is a reddened area that doesn't blanch but has intact skin. Stages III and IV pressure injuries are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively. A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? Covering the application with a warm, moist dressing and an occlusive outer wrap Rationale: The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. The remaining options are not measures that will enhance the effectiveness of therapy. The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should most likely suspect that the client has which diagnosis? Esophageal varices Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used to treat the conditions noted in the remaining options. The nurse has been providing care for a client with a Sengstaken-Blakemore tube. While the tube is inflated the nurse should monitor for which priority sign/symptom? Respiratory distress Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. When the balloon on the tube is inflated the nurse should monitor for respiratory distress which could indicate the balloon has ruptured. The nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the client's laboratory results and notes that the calcium level is extremely low. The nurse should expect to note which sign/symptom on data collection? Positive Trousseau's sign Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany. Options 1, 3, and 4 are not related to the presence of hypocalcemia. The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific signs of this complication should be included on the list? Increased thirst Rationale: The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition. The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data should be included? The client's vital signs, muscle strength, and previous activity level Rationale: Priority data related to vital signs, muscle strength, and previous activity level would be included. Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. The other data are also important, but physiological needs take precedence over psychosocial needs. The nurse is preparing a plan of care for a client in skeletal leg traction with an over bed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? Place a trapeze on the bed to provide a means for the client to lift the hips off the bed. Rationale: The nurse can best assist the client in skeletal traction with positioning in bed by providing a trapeze on the bed for the client's use. Encouraging the client to pull up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of positioning by the client. The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next? Notify the registered nurse. Rationale: A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client and if ineffective, would next notify the registered nurse, who will then contact the primary health care provider. Severe leg pain once traction has been established indicates a problem. Medicating the client would be done after trying to determine and treat the cause. The nurse would never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described. The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? Petal the cast edges with adhesive tape. Rationale: If a client with a cast has skin irritation from the edges of the cast, the appropriate intervention by the nurse would be to petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the primary health care provider. The nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment? Refer to figure. View Figure B Rationale: The dorsal recumbent position is the best position used for abdominal assessment because it promotes relaxation of abdominal muscles. In addition, clients with painful disorders are more comfortable with the knees flexed. The sitting upright position in option 1 provides full expansion of the lungs and visualization of the upper body parts. In option 3, the Sims' position is used for assessment of the rectal and vaginal area. The lithotomy position in option 4 is used for assessment of the female genitalia. The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply. 2. Knees 3. Elbows 5. Base of the spine Rationale: The plaques most often appear on the skin of the elbows, knees, and base of the spine of a client with psoriasis. The plaques do not often appear on the face or the abdomen. The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast? View Figure A hip spica cast Rationale: A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included it is called a single hip spica. If two are included it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso. The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? Select all that apply. 2. Use a shrinker stocking or sock to cover the wrapped stump. 4. Begin residual limb care when sutures or staples are removed. 5. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. 6. When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown. Rationale: After the sutures or staples are removed, the client begins residual limb care. The home care nurse tells the client and family that they can use a shrinker stocking or sock to cover the wrapped stump because it is easier to apply. The limb also needs to be inspected every day for signs of inflammation or skin breakdown. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. The limb should be rewrapped 3 times a day and not once a day with an elastic bandage. The elastic bandage should be applied in a figure- eight manner and never wrapped in a top-down manner. The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which? Autograft Rationale: It is most desirable to graft the client's own skin (autograft), but when this is not possible, a homograft (the skin of another person [allograft], obtained from a cadaver), a heterograft (xenograft, usually obtained from a pig), or artificial (biosynthetic) skin, such as Biobrane, can be used as a temporary measure. The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the primary health care provider's (PHCP) prescriptions and notes that the PHCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. View Figure C Rationale: A pelvic sling is a traction device consisting of a hammock-like belt wherein the sling cradles the pelvis in its boundaries. It is used for the treatment of one or more pelvic fractures. The first device identifies a cervical halter skin traction. The second device identifies a pelvic belt traction. The fourth device identifies Russell's traction. The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action? Stay with the victim. Rationale: The appropriate nursing action is to stay with the victim. Because the victim complains of severe leg pain, a fracture should be suspected. With a suspected fracture the victim is not moved unless it is dangerous to remain in that spot. While staying with the victim the nurse should have someone else call for emergency help. Before moving the client, the site of fracture is immobilized to prevent further injury. Moving the leg can cause further injury to the victim's leg. A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? Notify the registered nurse. Rationale: The nurse realigns the client, and, if ineffective, then notifies the registered nurse, who then calls the primary health care provider (PHCP). A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse never removes traction weights unless specifically prescribed by the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described. A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings the nurse should take which action? Notify the registered nurse. Rationale: The client with early acute compartment syndrome typically complains of severe, diffuse pain that is unrelieved with pain medication. The nurse notifies the registered nurse, who contacts the primary health care provider immediately. The other actions are inaccurate interventions. A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? Document the finding in the client's record. Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a primary health care provider's responsibility. The tube is weighted by a special substance and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. Options 1, 2, and 4 are incorrect nursing actions. The nurse would however keep the registered nurse informed about the progress of the tube advancement. The nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. Which action should the nurse implement? Check the client's capillary blood glucose. Rationale: The nurse must first obtain a blood glucose reading to determine the client's problem. Options 1 and 4 would be implemented as needed in the treatment of hypoglycemia. Insulin therapy is guided by blood glucose measurement. A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which should the nurse include in the plan of care? Select all that apply. 3. Administering pain medications as prescribed 5. Monitoring the donor site and the graft site for signs of infection Rationale: Donor sites may be covered by a film dressing to hasten healing and decrease pain; they are not left open to air. The donor site is often more painful than the graft site and pain medications are prescribed. The sites are monitored for infection. The graft area is immobilized for 3 to 7 days, not just 24 hours, to permit attachment of the graft to the wound base. Pressure dressings are worn as soon as grafts heal but not right after the procedure. The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history should the nurse determine is least likely associated with this disease? History of the use of acetaminophen for pain and discomfort Rationale: Unlike aspirin (acetylsalicylic acid), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. The data in options 1, 2, and 3, if reported by the client, are indications of peptic ulcer disease. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which data finding best indicates adequate location of the tube? The aspirate from the tube has a pH of 7.45. Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube. The nurse is providing care for a client with a nasogastric tube. Which observation is most appropriate in determining that the tube is correctly placed? The pH of the aspirate is 5. Rationale: After the nurse inserts a nasogastric tube into a client the correct location of the tube must be verified. The nurse follows the approved procedure for inserting a nasogastric tube including correct measurement and aspirating fluid with the visible characteristics of gastric fluid. The presence of blood (option 3) is unrelated to the location of the tube. Aspirate is dark green and the tube is inserted the length measuring from the client's ear to nose and nose to xiphoid process. However, testing the pH of the gastric fluid and determining its acidity is the most reliable verification that the tube is correctly placed. A client is admitted to the hospital with a diagnosed bowel obstruction secondary to a recurrent diagnosed malignancy. The primary health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which action should the nurse determine is best? Remain with the client and be silent. Rationale: The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 2, the nurse conveys acceptance of the client and uses the therapeutic communication technique of silence. Options 1, 3, and 4 block communication and do not address the client's need. A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client indicates an understanding of this occurrence? "I forgot to take my usual mid-afternoon snack yesterday." Rationale: Hypoglycemia is a blood glucose level of 60 mg/dL or less. The causes are multiple, but in this case, omitting the afternoon snack is the cause. Fatigue and self-adjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day. The nurse is assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client? Learn measures such as biofeedback or progressive relaxation. Rationale: Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed. The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted? Bowel movement every 5 days Rationale: Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (measurable by equal calf measurements and absence of pain or redness in the calf area), active baseline ROM to uninvolved joints, intact skin, and a bowel movement every other day. The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage? 36% Rationale: According to the rule of nines, the entire right leg equals 18%, and the anterior thorax equals 18%. This totals 36%. The nurse is reinforcing instructions to a client with diabetes mellitus about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should teach the client that which result is a sign of hypoglycemia? Less than 50 mg/dL Rationale: The principal adverse effect of insulin therapy is hypoglycemia. The normal blood glucose level ranges from 90 to 110 mg/dL. Therefore, option 1 is an indication of hypoglycemia. A calcium supplement is prescribed for a client diagnosed with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? "I need to add 0.5 ounce of mineral oil to my daily diet." Rationale: Clients taking antihypocalcemic medications should be instructed to avoid the use of mineral oil as a laxative because it decreases vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. Options 1, 2, and 3 are basic measures to alleviate constipation. The nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists in developing a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan? Toothbrushing will not be permitted for at least 2 weeks following surgery. Rationale: Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although coughing and deep breathing are important, specific to this procedure is avoiding toothbrushing to prevent disruption of the surgical site. Also, coughing may disrupt the surgical site. Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. Which is the initial nursing action? Check the urine specific gravity. Rationale: Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine for specific gravity and report the results if they are less than 1.005. Urinary glucose and diabetes mellitus are not a concern here. In this situation, increasing fluid intake would require a primary health care provider's prescription. The client's complaint would be documented but not as an initial action. The nurse is reviewing a primary health care provider's prescriptions for a client with newly diagnosed, untreated hypothyroidism. Which medication prescribed for the client should the nurse question and verify? Morphine sulfate Rationale: The client with hypothyroidism experiences fatigue, lethargy, and increased somnolence. The decreased metabolism and oxygen consumption is manifested by a slow heart rate, decreased cardiac output, and decreased blood pressure. Levothyroxine, a thyroid hormone, is a component of therapy. Stool softeners such as docusate sodium are prescribed to promote defecation. Morphine sulfate would further depress bodily functions. Atenolol is used with caution in clients with hyperthyroidism. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse who is assisting with care for the client obtains which item in preparation for the treatment of this syndrome? Intravenous (IV) infusion of normal saline Rationale: The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. A nasal cannula for oxygen administration is not necessarily required to treat HHS. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which finding should the nurse expect to note as confirming this diagnosis? Elevated blood glucose and low plasma bicarbonate Rationale: In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria and Kussmaul's respirations. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis. A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which item anticipating a primary health care provider's prescription? IV infusion containing 5% dextrose Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA; 50% dextrose is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA. A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care understanding that which statement accurately reflects this client's level of knowledge? The client needs immediate education before discharge. Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the primary health care provider should be notified. The client's statement in this question indicates a need for immediate education to prevent HHS, a life-threatening emergency situation. A primary health care provider has prescribed propylthiouracil for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. Which nursing measure would be included in the plan regarding this medication? Signs and symptoms of hypothyroidism Rationale: Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity. The nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse should focus on which potential problem for this client? Dehydration Rationale: Increased blood glucose will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes causing an osmotic diuresis that leads to dehydration. This fluid loss must be replaced when it becomes severe. Options 2, 3, and 4 may be concerns at some point but are not priorities with hyperglycemia. The nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for further teaching? "I need to stop my insulin." Rationale: When a client with diabetes is unable to eat normally because of illness, the client should still take the prescribed insulin or oral medication. Additional fluids should be consumed and a call placed to the primary health care provider. The client should monitor the blood glucose levels every 4 to 6 hours. The nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). Which is the priority nursing action for this client who is in the acute phase? Administer intravenous (IV) regular insulin. Rationale: Lack (absolute or relative) of insulin is the primary cause leading to DKA. Treatment consists of IV fluids (normal saline initially), regular insulin administration, and potassium replacement followed by correcting the acidosis. An ECG monitor may be applied but is not the priority in this situation. A client with type 2 diabetes mellitus has a blood glucose of more than 600 mg/dL and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the primary health care provider's documentation and would expect to note which diagnosis? Hyperglycemic hyperosmolar state (HHS) Rationale: Hyperglycemic hyperosmolar state is seen primarily in individuals with type 2 diabetes who experience a relative deficiency of insulin. The onset of symptoms may be gradual. The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. DKA normally occurs in type 1 diabetes mellitus. The clinical signs/symptoms noted in the question are not signs of hypoglycemia. Pheochromocytoma is not related to these clinical signs/symptoms. The nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse? Temperature Rationale: Elevated temperature may be indicative of infection, which is a leading cause of hyperglycemic hyperosmolar state (HHS) or diabetic ketoacidosis (DKA). Options 2, 3, and 4 are findings that are within a normal range. The nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client's learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn? The client complains of fatigue whenever the nurse plans a teaching session. Rationale: Physical symptoms can interfere with an individual's ability to learn and can indicate to the teacher that the learner lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. Options 1, 2, and 3 identify the client as actively seeking information. A client with diabetes mellitus visits the health care clinic. The client previously had been well controlled with glyburide, but recently the fasting blood glucose has been running 180 to 200 mg/dL. Which medication, if added to the client's regimen, may be contributing to the hyperglycemia? Prednisone Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 3, a beta blocker, and option 2, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents causing increased levels of the oral medications, which can lead to hypoglycemia. A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription. Rationale: Partial weight bearing usually is permitted 72 hours postoperatively per surgeon's preference but the nurse needs to check the surgeon's prescription. The client should keep the knees abducted with a wedge pillow. The client should not flex the hips any more than a 90-degree angle. Enoxaparin is given by injection, not by a tablet. A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action? Use the edge of a sterile surgical tool to scrape out the stinger. Rationale: Using the edge of a sterile surgical tool to scrape out the stinger will not likely squeeze any bee venom into the tissue. Tweezers likely would squeeze additional venom into the tissues. Applying warm compresses likely would cause additional absorption because of vasodilation. An occlusive dressing would not prevent tissue absorption and would not assist in removal of the stinger. A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures will most likely promote coping? Select all that apply. 1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 5. Ask the client to begin doing one part of the ostomy care each day and increase tasks daily. Rationale: A member of the local ostomy club will be able to provide realistic encouragement. The enterostomal nurse specialist will be able to provide helpful information to the client. Asking the client to assist with tasks may encourage the client to take on more advanced skills and become more adjusted to the ostomy. Reminding the client about the responsibility for caring for the colostomy and telling the client that infection is a major complication (which is incorrect) will alarm the client. Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching? "I can apply heat to my knee if it becomes uncomfortable." Rationale: There is a need for further teaching when the client says that heat is applied to the affected joint for pain and swelling. Ice needs to be applied, not heat. Also, analgesics are administered as prescribed. The client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return to the primary health care provider for follow-up in about 7 days. The nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates a need for further teaching regarding insulin pump therapy? "Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again." Rationale: All of the statements are correct in regard to insulin pump therapy, except the one that mentions insulin reactions and ketoacidosis. Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump. A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem? Obtaining dark glasses for the client Rationale: Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Medical therapy for Graves' disease does not help alleviate the clinical symptom of exophthalmos. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. There is no need to prevent straining with exophthalmos. The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period? Bleeding Rationale: Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must frequently check the neck dressing for bleeding and monitor vital signs to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Infection is a concern for any postoperative client, but it is not the priority in the immediate postoperative period. Urinary retention can occur in postoperative clients as a result of medication and anesthesia, but it is not the priority from the options provided. A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose value of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and is positive for serum ketones. The diagnosis is supported by which noted data? Select all that apply. 3. Fruity breath odor 4. Rapid, deep breathing 5. Dry mucous membranes Rationale: Diabetic ketoacidotic coma is usually identified with a fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing. Hypoglycemia is identified by cool, clammy skin; shakiness; and hunger. Which statement by the spouse of a client with diagnosed end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding management of the client's pain? "This opioid will cause very deep sleep, which is what my husband needs." Rationale: Changes in level of consciousness are an indicator of potential opioid overdose and are indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to overdose or deficits. All remaining options are indicative of an understanding of appropriate steps to be taken in the management of pain. The nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique would provide data necessary to support the admitting diagnosis? Inspection of facial features Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and a blank expression that are characteristic of myxedema. The techniques in the remaining options will not reveal any data that would support the diagnosis of myxedema. During admission data collection the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area? Balance and coordination Rationale: The nurse is testing cerebellar function, specifically ataxia to evaluate the client's balance and coordination. Examples of disorders that include interferences in this area could be Parkinson's disease, multiple sclerosis, or brain attack (stroke). This test does not identify the problems addressed in any of the other options. After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse should monitor the client closely for which priority esophageal complication? Hemorrhage Rationale: A Sengstaken-Blakemore tube is inserted in cirrhotic clients with ruptured esophageal varices when other measures are ineffective. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the exiting esophageal varices. The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse should determine which data indicates the client may have liver damage? Pruritus Rationale: Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel providing the normal brown color to stool. When bilirubin is not metabolized by the liver, it accumulates in the circulation and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys causing urine to become dark amber or brown. The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse most question? Acetaminophen Rationale: Acetaminophen can cause hepatotoxicity, and its use is avoided in the client with liver disease. Furosemide and omeprazole do not adversely affect liver function. Lorazepam can cause liver damage in high doses or with long-term therapy but can still be used (with caution) in the client with liver disease. A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action? Monitoring prothrombin and partial thromboplastin values Rationale: When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Daily weight is often part of a nursing care plan but is more related to fluid balance than safety; monitoring weight twice daily would not be necessary. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue either. The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding should the nurse recognize to be a direct result of this client's condition? Drowsiness Rationale: Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein by- products, especially ammonia, which are harmful to the central nervous system. An increased ammonia level is the primary cause of the neurological changes seen in liver disease beginning first with drowsiness. The remaining options are not directly related to hepatitis. A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care and places highest priority on which potential problem? Infection Rationale: The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection because of excess cortisol secretion and subsequent impaired antibody function and decreased proliferation of lymphocytes. The client may also have a potential for the problems listed in the other options, but these are not the highest priority at this time. A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion? Venous circulation is being impaired. Rationale: The blue color is a sign of venous engorgement resulting from venous stasis, which increases local tissue hypoxia and can lead to necrosis of the area affected. This is not a normal expectation. Heat application would cause more damage to the tissue. There is no evidence to support option 4. The nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement? "I should check my blood glucose level before eating each meal regardless of how much I eat." Rationale: The most effective and accurate measure for testing blood glucose is to test the level before each meal regardless of the amount of food to be eaten. The client should also check the blood glucose level at bedtime. Checking the level after the meal will provide an inaccurate assessment of diabetic control. Checking the level once daily will not provide enough data related to controlling the diabetes mellitus. The nurse is reinforcing dietary instructions to a client newly diagnosed with diabetes mellitus. The nurse accurately instructs the client with which statement? It is best to eat meals at approximately the same time each day. Rationale: Mealtimes must be approximately the same time each day to maintain a stable blood glucose level. The client should not be instructed that mealtimes are varied depending on blood glucose levels or insulin administration. Mealtimes should not be adjusted based on blood glucose levels or snacks. A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which? "Are you rotating the injection site?" Rationale: The client should be instructed that insulin injection sites should be rotated within one anatomical area before moving to another. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. Options 2, 3, and 4 are not associated with the condition (skin leakage of insulin) presented in the question. The nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The primary health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that which is the first step? Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. Rationale: The initial step in preparing an injection of insulin that is a mixture of NPH and regular is to inject air into the NPH bottle equal to the amount of insulin prescribed. The client is instructed to next inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin should then be withdrawn followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form. The nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. Which primary health care provider's prescription supports the treatment of this condition? An increased amount of NPH daily insulin Rationale: Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress such as when an infection exists, the client will require an increase in the dose of insulin to facilitate the transport of excess glucose into the cells. The client does not necessarily need an adjustment in the daily diet. The nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse review? Elevated pulse; shakiness; and cool, clammy skin Rationale: Symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin. Options 1, 2, and 4 are not symptoms of hypoglycemia. The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the early signs of this complication by checking which criteria? Select all that apply. 2. The client's mental status 4. The client's respiratory function Rationale: The earliest signs/symptoms of fat embolism include changes in the client's mental status or signs/symptoms of impaired respiratory function caused by impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment are likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs/symptoms of fat embolism. The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action? Place the client in a Fowler's position. Rationale: If the nurse suspects fat embolism, the initial action by the nurse is to place the client in a sitting (Fowler's) position to relieve dyspnea. Clients with fractures are at risk for fat embolism. Supplemental oxygen is indicated to reduce the signs of hypoxia. The primary health care provider needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions. The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs/symptoms of fat embolism. The nurse provides appropriate care by performing which action? Monitoring for signs of dyspnea Rationale: The signs/symptoms of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. The sign of maintaining external rotation of the right leg is indicative of the hip fracture itself. Monitoring the temperature regularly indicates signs of infection, and telling the client to report paresthesia of the right leg indicates signs of severe circulatory impairment. The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which finding does the nurse identify as early signs/symptoms of possible fat embolism? Increased heart rate and adventitious breath sounds Rationale: Early signs/symptoms of possible fat embolism are increased heart rate and adventitious breath sounds. Fat embolism commonly causes signs/symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The other findings are incorrect. The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? Check the neurovascular status of the toes on the casted leg. Rationale: The nurse's initial action is to check the neurovascular status of the toes on the casted leg. An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. The nurse needs to obtain additional data in order to determine whether the primary health care provider needs to be notified immediately or whether other interventions are appropriate. The other actions are inappropriate and would delay treatment if needed. The nurse is caring for a client who was just admitted with a diagnosis of fractured right femur. What are some of the acute complications the nurse needs to assess for? Select all that apply. 1. Crush syndrome 3. Fat embolism syndrome 5. Acute compartment syndrome (ACS) 6. Hemorrhage and hypovolemic shock Rationale: The nurse monitors the client for acute complications of fractures such as crush syndrome, fat embolism syndrome (FES), acute compartment syndrome (ACS), and hemorrhagic and hypovolemic shock. Infection is also another acute complication of fractures. Venous and not arterial thromboembolism is also an acute complication that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). Ischemic necrosis is a chronic complication. Clinical manifestations of beginning complications must be treated early to prevent serious consequences. The nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 3. Maintaining a low-sodium diet 5. Monitoring extremities for edema Rationale: The client with Cushing's syndrome experiencing fluid overload should be maintained on a high- potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis. A nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. A need for further teaching regarding this problem is identified when the nursing student suggests which nursing intervention? Evaluating the client's understanding that the body changes need to be dealt with Rationale: Evaluating the client's understanding that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. Options 1, 2, and 3 are appropriate because they address the client and family feelings regarding the disorder. The nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which signs and symptoms are related to adrenal insufficiency? Select all that apply. 1. Fever 2. Weakness 3. Hypotension 5. Mental status changes Rationale: The nurse should be alert to signs and symptoms of adrenal insufficiency in a client following adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. Double vision is generally not associated with this condition. The nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's syndrome. Which client statement reflects a need for further teaching? "I need to read the labels on any over-the-counter medications I purchase." Rationale: The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the primary health care provider before purchasing any over-the-counter medications, and maintaining regular follow-up care. The nurse should also instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism. The nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing interventions are appropriate components of the plan of care? Select all that apply. 1. Monitoring intake and output 3. Monitoring for changes in mental status 5. Encouraging fluid intake of at least 3000 mL/day Rationale: The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which primary health care provider's prescription noted on the record indicates the need for clarification? Apply a loose dressing if any clear drainage is noted. Rationale: The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted following this procedure, the primary health care provider needs to be notified immediately. Options 1, 2, and 4 indicate appropriate postoperative interventions. The nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which nursing intervention should the nurse include in the plan of care? Monitor neck circumference frequently. Rationale: Following a thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site because it could affect breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored at least every 4 hours to assess for postoperative edema. The nurse is monitoring a client following a thyroidectomy for signs/symptoms of hypocalcemia. Which signs/symptoms noted in the client indicates the presence of hypocalcemia? Select all that apply. 2. Muscle spasms 3. Positive Trousseau's sign 5. Tingling around the mouth Rationale: Following a thyroidectomy, the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and fingertips, muscle twitching or spasms, palpitations or dysrhythmias, and positive Chvostek's and Trousseau's signs. Options 1 and 4 are not signs of hypocalcemia. The nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. Which statement regarding the hoarseness should the nurse make? The hoarseness is normal and will gradually subside. Rationale: Hoarseness that develops in the postoperative period is usually the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. Options 1, 2, and 3 are incorrect. The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs and symptoms noted in the client should alert the nurse to the presence of this crisis? Select all that apply. 2. Fever 3. Sweating 4. Agitation Rationale: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical signs/symptoms include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur. Which client is at risk for developing thyrotoxicosis? A client with Graves' disease who is having surgery Rationale: Thyrotoxicosis is usually seen in clients with Graves' disease with the symptoms precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, the birth process, or major surgery. It also must be recognized as a potential complication following a thyroidectomy. The nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide. The nurse reinforces dietary instructions to the client. Which are appropriate instructions? Select all that apply. 2. Drink at least 2 to 3 L of fluid daily. 3. Increase dietary intake of potassium. Rationale: The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption. This is aided by the sufficient intake of fluids. Dietary restriction of calcium may be used as a component of therapy. The parathyroid is responsible for calcium production, and the term hyperparathyroidism can be indicative of an increase in calcium. The client should eat foods high in potassium, especially if the client is taking furosemide. Limiting nutrients is not advisable. Remember the inverse relationship between calcium and phosphorus. The nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further teaching? Select all that apply. 3."I need to limit playing football to only the weekends." 5."I should exercise in the evening to encourage a good sleep pattern." Rationale: The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity. The nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which item in the diet? Vegetables Rationale: The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables are allowed in the diet. The nurse has reinforced home care measures to a client diagnosed with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further teaching? "I should perform my exercise at peak insulin time." Rationale: The client should be instructed to avoid exercise at peak insulin time because this is when a hypoglycemic reaction is likely to occur. If exercise is performed at this time, the client should be instructed to eat an hour before the exercise and drink a carbohydrate liquid. Options 2, 3, and 4 are correct statements regarding exercise, insulin, and diabetic control. The nurse is caring for a client newly diagnosed with diabetes mellitus. The client asks the nurse whether eating at a restaurant will affect the diabetic control and whether this is allowed. Which nursing response is appropriate? "You should order a half-portion meal and have fresh fruit for dessert." Rationale: Clients with diabetes mellitus are instructed to make adjustments in their total daily intake to plan for meals at restaurants or parties. Some useful strategies include ordering half portions, salads with dressing on the side, fresh fruit for dessert, and baked or steamed entrées. Clients are not instructed to avoid any food group or to increase their prescribed insulin dosage. A client who is managing diabetes mellitus with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which diet would be appropriate for the client? Small frequent meals with protein, fat, and carbohydrates at each meal Rationale: The definition of hyperinsulinism is an excessive insulin secretion in response to carbohydrate- rich foods leading to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism contains proteins and fats whenever carbohydrates are consumed and is delivered in frequent but portion- controlled meals. Diets high in soluble fiber may be beneficial. A client has a noninfected pressure injury on the left heel. The nurse should use which sterile solution to cleanse the wound as part of a dressing change procedure? Normal saline Rationale: Normal saline (0.9%) should be used for cleansing pressure injuries, unless there is a specific prescription for another solution. Normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do). The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse should determine that which data noted in the record indicate poor absorption of dietary fats? Steatorrhea Rationale: The pancreas makes digestive enzymes that aid absorption. Chronic pancreatitis interferes with the absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. Steatorrhea by definition is excess fat in stools often caused by malabsorption problems. Options 2, 3, and 4 are rarely associated with chronic pancreatitis. A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions should the nurse take before transferring the client to the burn center? Select all that apply. 1. Apply cool water to the area. 4. Wrap burned fingers separately to prevent sticking together. 5. Cover the burns with a clean dry cloth as directed by a burn center. Rationale: Cool water is applied until the burned area is cool. Butter, lotions, ice, medications, or absorbent materials are never applied. The nearest burn center is contacted for instructions before applying any dressing. The rescuer may be advised to cover burns with a clean, dry dressing or cloth. Burned fingers and toes are wrapped separately to prevent sticking together. The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action? Monitor the client for signs of infection. Rationale: The client is recovering from extensive burns. The burn client is prone to several complications such as infection and sepsis. A temperature of 102.8° F is significant. On the fourth hospital day, infection may be the problem. The site of the infection may be the burns, the parenteral nutrition infusion or parenteral nutrition site, or other problems. As an initial action, the nurse needs to check the client for signs of infection and then notify the registered nurse, who will contact the health care provider for further prescriptions. A client is admitted to an acute care facility with complications of celiac disease. Which question asked by the nurse initially should be most helpful in obtaining information for the nursing care plan? "What is your understanding of celiac disease?" Rationale: Celiac disease is also known as "gluten-induced enteropathy." It causes diseased intestinal villi that result in decreased absorptive surfaces and malabsorption syndrome. Clients with celiac disease must maintain a gluten-free diet, which eliminates all products made from wheat, rye, oats, barley, buckwheat, or graham. Many products may contain gluten without the client's knowledge. Beer, pasta, crackers, cereals, and many more substances contain gluten. It is often very difficult for a client to learn all of the food substances that must be eliminated from a diet. Also it is often very difficult for a client to adhere to a strict diet. Therefore, initially it is important for the nurse to determine the client's understanding of the disease. The remaining options are appropriate questions but are not important initially. A client is seen in the ambulatory care office for a routine examination. Which statement by the client should be most important for the nurse to follow up? "I just lost a family member to gastrointestinal cancer." Rationale: The nurse should recognize and follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him, and the nurse should gather further data to understand the client's situation. Gathering data about the types of cancer, age, and sex of affected family members and the presence of other risk factors provides the needed information to initiate preventive education. Options 2, 3, and 4 require follow-up but do not have the priority that the correct option has. A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom associated with a hiatal hernia should the nurse recognize? Heartburn and regurgitation Rationale: Although many clients with a hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Options 1, 2, and 4 are not related to this disorder. The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement is most appropriate to be included in the teaching? "Avoid lying down for an hour after eating." Rationale: Most clients with a hiatal hernia can be managed by conservative measures, which include a low- fat diet, avoiding lying down for an hour after eating, and raising the head of the bed. The nurse should document that a client diagnosed with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? Eating low-fat or nonfat foods Rationale: The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Implemented treatment measures for a client with a diagnosis of bleeding esophageal varices have been unsuccessful. The primary health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse should prepare for insertion of this tube via which route? Nasogastric Rationale: A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect, because this tube is not inserted in those manners. The nurse is caring for a client with a Sengstaken-Blakemore tube. To effectively prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to implement which action? Provide frequent oral and nasal care on a regular basis. Rationale: Frequent oral and nasal care is necessary to prevent irritation to the mucosa. A family member's presence will not prevent this from occurring nor will the actions taken in options 1 and 2. Keeping scissors at the bedside is a good action; however, these are used to cut the tube if the client begins to have airway maintenance problems. A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse should determine that which data would further support this diagnosis? History of chronic obstructive pulmonary disease with weight loss Rationale: History of chronic obstructive pulmonary disease is commonly associated with gastric ulcers, because this disease increases gastric acid secretion. Weight loss is also associated with gastric ulcer disease. The other options do not contain risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Spicy foods often have been blamed for ulcers, but this link has not been proven. The nurse should include which most appropriate information when reinforcing home care instructions for a client who has been diagnosed with peptic ulcer disease? Learn to use stress reduction techniques. Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client also should avoid intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances. The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which action should the nurse encourage the client to do? Eat anything as long as it does not aggravate or cause pain. Rationale: The client may eat foods as long as they do not aggravate or cause pain. Increased GI motility should be avoided. A traditional bland diet is no longer recommended. It is unnecessary for the client to eat six small meals per day with this disorder, although smaller meals are better managed by the client. The nurse has been reinforcing dietary teaching for a client diagnosed with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client? A decrease in sour eructation Rationale: A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome. Options 2 and 3 are not consistent with minimizing disease symptoms. Option 4 represents healthy behavior by the client, but it is not as positive as is the correct option. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which considerations concerning ongoing self-management should the nurse reinforce to the client? Select all that apply. 1. Eat smaller and more frequent meals. 3. Drink fluids between meals not with them. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals not with them to avoid dumping syndrome. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client requires ongoing medical supervision and evaluation. The nurse who is reinforcing instructions to a client who has had a gastric resection should include which considerations? Select all that apply. 1. Eat small frequent meals. 3. Take action to prevent dumping syndrome. Rationale: After a gastrectomy, small frequent meals are given until the stomach stretches enough to tolerate three regular meals a day. Dumping syndrome occurs in many clients after GI surgery and may occur as an early or late complication. Upper GI hemorrhage also may occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks the intrinsic factor needed for absorption. Instead the client requires injection to supplement this vitamin. Iron supplements are necessary to help absorption of parenteral vitamin B12. The nurse should reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? Regular monthly injections of vitamin B12 will prevent this complication. Rationale: Vitamin B12 deficiency occurs from the lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Replacement therapy is given by the parenteral route. Symptoms generally occur within 5 years or less. Although not fatal, pernicious anemia can contribute to many other diseases. Not all diets are deficient in all of the B vitamins. The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention? Irrigating the nasogastric (NG) tube Rationale: After gastric surgery the nasogastric tube should not be irrigated. To do so may cause the suture line in the stomach to tear. Bowel sounds should be assessed, the drainage from the NG tube should be measured, and the tube should be kept to suction to be sure the stomach does not become distended. The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function? The transfer of digested food molecules from the GI tract into the bloodstream Rationale: Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Option 1 is an incorrect statement. A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? A tube with a larger lumen and an air vent Rationale: A Salem sump tube is used commonly for gastric intubation and has a larger suction lumen and an air vent. Option 1 describes a Levin tube. Option 2 describes a tube used for small intestinal feedings. Option 3 describes a tube used for gastroesophageal bleeding. The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse should anticipate a prescription to set the suction to which pressure? Low and intermittent Rationale: A Levin tube has no air vent, and the suction must be placed on an intermittent setting to prevent trauma to the gastric mucosa. Low pressure and intermittent suction is safer for the stomach than high pressure and continuous suction. A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should reinforce instructions to the client about the need for which supplements? Select all that apply. 2. Iron supplements 4. Calcium supplements 5. Vitamin B12 injections Rationale: Gastric surgery can have serious effects on the client's nutritional status. The absorption of vitamin B12, folic acid, iron, calcium, and vitamin D may be impaired, so supplements will be needed. Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Antibiotic therapy and antacid use would not help treat the lack of intrinsic factor or absorption of vitamins. The client in an emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. 1. Milk of magnesia 2. Heat pad to the abdomen Rationale: A client with right lower quadrant abdominal pain may have appendicitis. This client would be NPO and given intravenous (IV) fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; heat might bring enough blood and fluid to the appendix to cause it to rupture and cause peritonitis; therefore, the nurse would question the cathartic prescription and heat application. A client with diabetes mellitus decides to exercise an extra 30 minutes. The client is now experiencing hypoglycemia. Hypoglycemia is supported by which noted data? Select all that apply. 1. Hunger 2. Shakiness 3. Cool, clammy skin Rationale: Hypoglycemia is identified by cool, clammy skin; shakiness; and hunger. Diabetic ketoacidotic coma is usually identified with a fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing. A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? Abductor splint Rationale: Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning. A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? Cold Rationale: Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the client with a vertebral fracture. The use of cold is incorrect because ice is applied to a site for only the first 24 hours after an injury. Application of ice to the spine of a client could be uncomfortable, increase spasms, and result in feeling chilled. The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? Rationale: The postoperative hip surgery client understands the material presented when the client plans to use a raised toilet seat. It is important for clients with an insertion of a femoral head prosthesis to use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction? A. "You will need to let me know when you start to get feeling back in your legs." A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? A. Check the neurovascular status of the affected extremity. A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on doing which of the following while caring for the client? A. Ensuring that the weights on the traction setup are hanging free The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply. 1.Older clients 2.Obese people 4.Postmenopausal women 6. Clients with cardiovascular health problems The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching? "I don't need to be worried if the shape of my knee changes." A nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which of the following harmful effects can occur as a result of uncontrolled muscle pain? A. Weakness The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound- suction device. Based on this amount of drainage, which action is appropriate? 1. Document the findings. A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse would pay particular attention to monitoring for which of the following high-risk areas for pressure and breakdown? A. Right heel The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? Small pillows (Rationale: Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.) A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action? Ensure that the weights on the traction setup are hanging free. An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the primary health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem? Risk for constipation A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease? Adjust insulin according to capillary blood glucose levels. Rationale: There are many learning goals for the client who is newly diagnosed with diabetes mellitus. The client must learn dietary control, medication management, and proper exercise in order to control the disease. As a first step, the client learns to adjust medication (insulin) according to blood glucose results as prescribed by the primary health care provider. The client should then focus on long-term dietary control and weight loss, which will often lead to a decreased need for insulin. At the same time that diet is being controlled, the client should begin a regular exercise program to aid in weight loss. A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which action to perform the procedure properly? Let the arm hang dependently and milk the digit. Rationale: Before doing a finger stick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures may lead to pain and bruising. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining a good-sized blood drop. The nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. Which information should be a component of the instructions? Instructions about early signs of a wound infection Rationale: A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Because of the anti-inflammatory properties of corticosteroids, clients who undergo an adrenalectomy are at increased risk for developing wound infections. Because of this increased risk for infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection is present. Options 1, 3, and 4 are incorrect instructions. The nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which beverage does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally? Mineral water Rationale: Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates. A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate? "You have concerns about the surgical treatment for your condition?" Rationale: Paraphrasing is restating the client's message in the nurse's own words. Option 2 addresses the therapeutic communication technique of paraphrasing. The client is reaching out for understanding. In option 4, the nurse is offering a false reassurance, and this type of response will block communication. Option 3 also represents a communication block because it reflects a lack of the client's right to an opinion. In option 1, the nurse is expressing approval, which can be harmful to the nurse-client relationship. The nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which value needs to be reported? Potassium 3.1 mEq/L Rationale: The client with diabetic ketoacidosis initially becomes hyperkalemic as potassium leaves the cells in response to lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse carefully monitors the results of serum potassium levels and reports hypokalemia (option 1) promptly. The other laboratory values are within the normal ranges. A client is admitted with a diagnosis of pheochromocytoma. The nurse should monitor which parameter to detect the most common sign of pheochromocytoma? Blood pressure elevation Rationale: Hypertension is the major symptom associated with pheochromocytoma and is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the most common sign. In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate? High in calcium and low phosphorous Rationale: Hypocalcemia is the end result of hypoparathyroidism resulting from either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus because these two electrolytes must exist in inverse proportions in the body. The other options are not dietary interventions with hypoparathyroidism. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate? "Usually, these physical changes slowly improve following treatment." Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 4 are not therapeutic responses. After receiving furosemide 40 mg slow intravenous push for chest pain related to shortness of breath and generalized edema, the client responds poorly. The client has no relief of the chest pain, shortness of breath, or edema and only minimal urine output (less than 40 mL of urine). The primary health care provider is notified, and after reviewing the chart, suspects the client has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings would lead to this specific diagnosis? Refer to chart. View Chart Minimal responsiveness to furosemide and small cell lung cancer Rationale: The minimal responsiveness to furosemide combined with the generalized edema, shortness of breath, and history of small cell lung cancer suggest SIADH. Although hypertension and weight gain are common in SIADH, they are also common in other diseases such as heart failure. A seizure disorder does not place a client at higher risk for SIADH, but a lower sodium level through dilution is common in SIADH. The increased pulse could be a compensatory mechanism for the blood pressure, the retained fluid, and weight gain. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. Which intervention would be appropriate to decrease the client's anxiety? Convey empathy, trust, and respect toward the client. Rationale: The appropriate intervention is to address the client's feelings related to the anxiety and to convey empathy, trust, and respect toward the client. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists. The nurse is instructing a client with Addison's disease about a newly prescribed medication, fludrocortisone acetate. Which statement by the client indicates a need for further teaching? "I will be glad to gain weight." Rationale: The client should notify the primary health care provider of weight gain. The client should take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone acetate should not be stopped abruptly but should be tapered down. While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as which? A finding that needs to be reported immediately Rationale: An adrenalectomy is performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, which puts the client at risk for infection. Because of this, the client needs to be protected from infection, and minor variations in normal vital sign values must be reported so that infections are detected early before they become overwhelming. In addition, the surgeon may elect to postpone surgery in the event of a fever because it can be indicative of infection. Options 1, 3, and 4 are not correct interpretations. The nurse has just supervised a client who has newly diagnosed diabetes mellitus self-inject NPH insulin at 7:30 am. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction during which time frame? 1:30 pm and 7:30 pm Rationale: NPH is an intermediate-acting insulin. It begins to work in 1 to 2 hours (onset), peaks in 6 to 12 hours, and lasts for 18 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak time, which in this case is option 2. A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 am. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which signs and symptoms in the late afternoon? Hunger; shakiness; and cool, clammy skin Rationale: The client taking NPH insulin obtains peak medication effects approximately 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse should teach the client to watch for signs and symptoms of hypoglycemia including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. The other options list various signs and symptoms of hyperglycemia. The nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen? "The medication that I am taking helps release the insulin I already make." Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose use and need to be taken on a regular schedule as prescribed. To maintain normal blood glucose levels throughout the day, oral hypoglycemic agents such as metformin are not taken on an as-needed basis depending on the blood glucose levels. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available or effective because of the breakdown of the insulin by digestion. The nurse is caring for a client with Addison's disease. The diagnosis is supported by which noted data? Select all that apply. 2. Weight loss 4. Skin hyperpigmentation 5. Orthostatic hypotension Rationale: Addison's disease is a decreased secretion of the adrenal cortex. Signs and symptoms include orthostatic hypotension, decreased body hair, weight loss, skin hyperpigmentation, and progressive weakness. A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which liquid? Milk Rationale: Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption. A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action? Test the drainage for glucose. Rationale: Following hypophysectomy the client should be monitored for rhinorrhea (clear nasal drainage), which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for the presence of CSF by testing it for glucose. CSF tests positive for glucose, whereas true nasal secretions would not. It is not necessary to test drainage that is clear for occult blood. The head of the bed should not be lowered to prevent a rise in intracranial pressure. Continuing to observe the drainage without taking action could put the client at risk for developing a serious complication. A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which finding should the nurse note as being consistent with this diagnosis? High serum glucose level and low serum bicarbonate level Rationale: In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The arterial pH is low (less than 7.35.) The plasma bicarbonate is also low. The client would exhibit polyuria and Kussmaul's respirations. The potassium level usually is elevated as a result of dehydration. During data collection on a postoperative client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complication of this surgery, the nurse should check which parameter next? Urine specific gravity Rationale: Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess specific gravity and notify the registered nurse if the results are less than 1.005. Although options 1, 2, and 3 may be components of the assessment, the nurse would next check urine specific gravity. A client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. Which action should the nurse tell the client to do? Keep snacks in carry-on luggage to prevent hypoglycemia during the flight. Rationale: A frequent concern of diabetics during air travel is the availability of food at times that correspond with the timing and peak action of the client's insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand. Insulin equipment and supplies should always be placed in carry-on luggage (not checked). This provides ready access to treat hyperglycemia, if needed, and prevents loss of equipment if luggage is lost. Options 1 and 2 are unnecessary. The nurse has provided diabetic teaching with the family of a client newly diagnosed with diabetes. The nurse determines that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which condition? Hypoglycemia from insulin overdose Rationale: Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, consciousness usually returns within 20 minutes of glucagon injection. Once the client has regained consciousness, oral carbohydrates should be given. The other options are incorrect. A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse should place highest priority on completing which action first? Administering oxygen Rationale: As part of maintaining a patent airway, oxygen would be administered first. This would be quickly followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones. The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care knowing that which problem has the highest priority for this client? The possibility of injury as a result of decreased sensation in the legs and feet Rationale: The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Thus the highest priority problem is option 4, which can be determined using Maslow's Hierarchy of Needs Theory. Options 2 and 3 represent problems that are more psychosocial in nature and as such are secondary needs using Maslow's theory. Option 1 is incorrect because intermittent claudication is not directly associated with diabetic neuropathy. The nurse is caring for a client newly diagnosed with type 1 diabetes mellitus. In reviewing the medical record the nurse should note which signs and symptoms? Select all that apply. 2. Polyphagia 5. Extreme thirst 6. Rapid weight loss Rationale: Signs and symptoms of type 1 diabetes mellitus include extreme thirst (polydipsia), extreme hunger (polyphagia), frequent urination (polyuria), and rapid weight loss. Signs and symptoms of type 2 diabetes mellitus include weight gain, poor healing, blurred vision, and itching. The nurse is discussing foot care with a diabetic client and the spouse. The nurse includes which instruction during this informational session? The toenails should be cut straight across. Rationale: The client should be instructed to cut the toenails straight across. The client should not soak the feet in hot water to prevent burns. The client should be instructed to wash the feet daily using a mild soap. Moisturizing lotion can be applied to the feet but should not be placed between the toes. The nurse is caring for a postoperative adrenalectomy client. Which finding does the nurse specifically monitor for in this client? Signs and symptoms of hypovolemia Rationale: Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. A deficiency of adrenocortical hormones does not cause the signs/symptoms noted in options 1, 2, and 4. The nurse is caring for a client with hypothyroidism who is overweight. Which food items should the nurse suggest to include in the plan? Skim milk, apples, whole-grain bread, and cereal Rationale: Clients with hypothyroidism may have a problem with being overweight because of their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories. Option 4 is the only option that identifies food items that are low in calories. A client has been diagnosed with hypoparathyroidism. Which food groups should be included in the diet? Low in phosphorus and high in calcium Rationale: Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder is one that is high in calcium but low in phosphorus because these two electrolytes have inverse proportions in the body. All of the other options are unrelated to this disorder and are incorrect. When caring for a client diagnosed with pheochromocytoma, which signs and symptoms should the nurse note? Select all that apply. 3. Severe headache 4. Profuse diaphoresis 5. Severe hypertension Rationale: Pheochromocytoma is a catecholamine-producing tumor of the adrenal gland and causes secretion of excessive amounts of epinephrine and norepinephrine. Signs and symptoms of pheochromocytoma are related to excess catecholamine release. These include tachycardia and severe hypertension (as high as 250/150 mm Hg) that can be intermittent or persistent. Profuse diaphoresis, severe headache, palpitations, nausea, weakness, and pallor may also be present. A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this symptom, the nurse should incorporate which knowledge? It may slowly improve with treatment of the disorder. Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve over time with treatment. The other options are incorrect. The nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, should the nurse determine as being likely related to the symptoms of this disorder? Depression Rationale: Hypothyroid clients experience a slow metabolic rate, and its manifestation includes apathy, fatigue, sleepiness, and depression. Options 1, 2, and 4 identify the clinical symptoms of hyperthyroidism. The nurse is collecting data on a client with hyperparathyroidism. Which question would elicit accurate information about this condition from the client? "Are you experiencing pain in your joints?" Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood causing hypercalcemia. The bones suffer demineralization as a result of calcium loss leading to bone and joint pain and pathological fractures. A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which should be acceptable to take before the test? Water Rationale: When a client is scheduled for a fasting blood glucose level, the client should not eat or drink anything except water after midnight. This is needed to ensure accurate test results, which form the basis for adjustments or continuance of treatment. Options 2, 3, and 4 are inaccurate, and the client should not consume these items before the test. What is included in the treatment of Addison's disease? Select all that apply. 2. Prednisone 5. Fludrocortisone Rationale: Addison's disease is treated with replacement therapy to provide the missing hormones, but the patient must continue taking the hormones as lifelong therapy. Prednisone is given to replace glucocorticoids; fludrocortisone is a synthetic adrenocortical steroid to replace the mineralocorticoid aldosterone. Cushing's syndrome treatment includes drug therapy, radiation, and surgery. Bilateral benign tumors more often are treated with an aldosterone antagonist agent (i.e., a drug that reduces aldosterone secretion or blocks its effects such as potassium-sparing diuretic spironolactone. Glucagon hydrochloride injection would most likely be prescribed for which disorder? Type 1 diabetes mellitus Rationale: Glucagon hydrochloride is a medication that can be administered subcutaneously or intramuscularly. It is prescribed to stimulate the liver to release glucose when a client is experiencing hypoglycemia and unable to take oral glucose replacement. It is important to teach a person other than the client how to administer the medication because the client's symptoms may prevent self-injection. Therefore, options 1, 2, and 4 are incorrect. A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all that apply. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 4. A time-out is performed before the procedure. 6. A local anesthetic is administered before the procedure. Rationale: A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion is verified. A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. A lung biopsy is often done during a bronchoscopy. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply. Notify the RN. 1. 4. Discontinue suctioning until the client is stabilized. Rationale: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified. The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 mL/hour to 100 mL/hour is considered excessive and requires RN and PHCP notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. Excessive and/or vigorous bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? Continue to monitor. Rationale: The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her (client) breath. The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. Cover the site with an occlusive dressing after the tube is removed. 2. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out. Rationale: A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight (occlusive) dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, the client should take deep breaths to ensure adequate lung expansion. The tube is not usually clamped before it is removed, and the drainage apparatus must always be lower than the chest tube site. The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. Rationale: The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be air tight (no leaks), and all connections should be tapes and secure. It is important that the tubes to the suction and the chest tube be patent (without kinks or obstructions). Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, air pressure causes air to rush in, and lung collapse can occur. The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? Palpating the skin around the chest and neck for a crackling sensation Rationale: Air caught under the skin in the subcutaneous tissues is known as crepitus or subcutaneous emphysema. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Auscultation of posterior breath sounds gives data about adequate depth of respirations. Pain upon inspiration can occur with pleurisy (inflammation of the pleurae) or pericarditis. Placing the hands over the rib area is a method of determining equal chest expansion on each side. The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak 3. Must have the cuff deflated when capped Rationale: A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped. When the cuff is inflated, the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube. The client continues to need cleaning of the tracheostomy site. The client is unable to breathe through the tracheal opening or at all if the cuff is inflated and the opening capped. The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume? Sitting on the side of the bed leaning on an overbed table Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing. The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis? Sputum culture Rationale: A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding should be reported immediately to the primary health care provider (PHCP)? Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply. 1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment. The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which? Promote carbon dioxide elimination Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR. The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? Lateral position Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated. The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? Respiratory distress Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected. The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? Shortness of breath Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss. The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? A man who is an inspector for the U.S. Postal Service Rationale: People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users. The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 5. Pain that occurs most often during inspiration Rationale: Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is abrupt and severe pain. The pain almost always occurs on one side of the chest. Pleurisy pain is sharp, knife- like, and abrupt in onset and is most evident during inspiration. This causes shallow breathing. A pleural friction rub may be heard. The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority? Report the findings. Rationale: The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client. A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely? The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug- resistant tuberculosis. The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made? "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client continues medication therapy for 6 to 12 months depending on the situation. The client is generally considered to not be contagious after 2 to 3 weeks of medication. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative. The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen? 2 L/min Rationale: Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long- standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system. The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. Rationale: Intermittent suction is applied while rotating the catheter for up to 10 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 mm Hg to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues. A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? Peripheral neuritis Rationale: An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesia in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply. 2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, and dyspnea during exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough particularly when arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? Coughing occurs with suctioning. Rationale: Coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. The client should be encouraged to cough to help with removal of secretions from the lungs. The nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse oximetry falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these signs to the PHCP immediately. The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications? Changing the client's position every 2 hours Rationale: Frequent position changes help mobilize lung secretions and prevent pooling. This is the only intervention identified in the options that will prevent respiratory complications. The nurse should encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. It is important to encourage coughing and deep breathing to mobilize lung secretions. The nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. The client should be instructed to avoid the Valsalva maneuver or any activity that involves holding the breath. A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply. 2. "My family and I will practice good hand hygiene." 3. "I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh." Rationale: TB is spread by droplet nuclei or by the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique. It is unnecessary to remove carpeting from the home. The client should protect others by covering the mouth when coughing, laughing, or sneezing. The client and family should wash hands often. Disposable tissues should be used and discarded in a plastic bag. client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience? Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well. The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles? Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary. The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery? Obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times in case the tracheostomy tube is dislodged. In addition, a curved hemostat that could be used to hold the trachea open, if dislodgment occurs, should also be kept at the bedside. An oral airway and epinephrine would not be needed. The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high- pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention? Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. A disconnection or a cuff leak can result in the sounding of the low-pressure alarm. The respiratory therapist should be notified if the nurse could not determine the cause of the alarm. The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen? Have the client take three deep breaths. Rationale: To obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. The client should then take three deep breaths and cough into a sputum specimen container. The client should be encouraged to cough and not spit so that sputum can be obtained. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning. The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax? Shortness of breath Rationale: The client has sustained a blunt or a closed chest injury. This type of injury can result in a closed pneumothorax. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. The presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note? Hyperinflated lungs on chest x-ray Rationale: Signs/symptoms of chronic obstructive pulmonary disease include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly? The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold his or her breath. The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding? Complaints of night sweats Rationale: The client with tuberculosis usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease. The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement? "After maximal inspiration, I will hold my breath for 10 seconds and then exhale." Rationale: For optimal lung expansion with the incentive spirometer, the client should assume a semi- Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips. The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make? The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. The remaining options are incorrect interpretations of the finding. The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next? Notify the registered nurse (RN). Rationale: If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the primary health care provider (PHCP). The nurse should maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings should assist in determining the client's respiratory status, but the priority action should be to notify the RN, who will then call the PHCP. A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter? Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. If possible, the nurse should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure? Administer pain medication 15 to 30 minutes before the procedure. Rationale: Removal of chest tubes can be uncomfortable for a client. The nurse should medicate the client 15 to 30 minutes before the chest tube is removed. The remaining options are inappropriate actions and would not be performed by the nurse. The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter? 10 seconds Rationale: During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client. The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? Aspiration of gastric contents occurs when suctioning. Rationale: Necrosis of the tracheal wall in a client with a tracheostomy can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 3, and 4 are not signs of this complication. A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What should the nurse do immediately? Put open end under sterile water. Rationale: If the chest tube becomes unattached, do not clamp the tube; place the end of the tubing in a container of sterile water. This creates a "water seal" and can prevent tension pneumothorax. The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure. A Rationale: The client is placed in the Fowler's position for nasotracheal suctioning. This position promotes lung expansion and is also the preferred position for eating and nasogastric tube insertion. Option 2 identifies Trendelenburg's position. This position is used for postural drainage and facilitates venous return in clients with poor peripheral circulation. Option 3 identifies reverse Trendelenburg's position. This position promotes gastric emptying and prevents esophageal reflux. Option 4 identifies a flat position that is used for clients with vertebral injuries and for clients in cervical traction. A flat position also may be used for clients who are hypotensive. The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement? Stop the suctioning procedure. Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxia. If hypoxia occurs during suctioning, the nurse stops the suctioning procedure. Using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the catheter should not exceed half of the size of the tracheal lumen. In adults, the standard catheter size is 12 to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia. The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action should be immediate? Reattach the chest tube to the drainage system. Rationale: In most situations, clamping chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. The nurse would also notify the registered nurse of the occurrence. The primary health care provider will need to be notified, but this is not the immediate action. The client would not be instructed to inhale. The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement? Cover the insertion site with sterile gauze. Rationale: If a chest tube dislodges from the insertion site, the nurse immediately covers the site with sterile Vaseline gauze. The nurse would then notify the registered nurse, assist the client back to bed, and perform a respiratory assessment on the client. The registered nurse would then contact the primary health care provider. The nurse does not reinsert a chest tube. The primary health care provider will reinsert the chest tube if necessary. The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action? Ventilate the client with a resuscitation bag. Rationale: Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or primary health care provider. The nurse also notifies the registered nurse (RN) of the occurrence and obtains assistance from the RN The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement? Check the amount of suction pressure being applied. Rationale: The return of bloody secretions is an unexpected outcome related to suctioning. If this occurs, the nurse should first assess the client and then determine the amount of suction pressure being applied. The amount of suction pressure may need to be decreased. The nurse also needs to be sure that intermittent suction and catheter rotation are being done during suctioning. Continuing with the suctioning or vigorous suctioning through the mouth will cause increased trauma and thus increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. Therefore, it is unlikely that the client will be able to cough out the bloody secretions. The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response? Disconnect the suction source from the catheter. Rationale: The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse would immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse would then connect the oxygen source to the catheter. The nurse also notifies the registered nurse who then notifies the primary health care provider. The primary health care provider will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning. A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? Check the client for spontaneous breathing. Rationale: If unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance from the registered nurse, and prepare for reintubation. There are no data in the question to indicate that a code needs to be called. The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which should the nurse do first? Check for kinks in the chest drainage system. Rationale: If the nurse notes that a chest tube is not draining, the nurse would first check for a kink or possible clot in the chest drainage system. The nurse then notifies the registered nurse and observes the client for respiratory distress or mediastinal shift (if this occurs, the primary health care provider is notified). Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client's chest tube is done when the fluid drainage chamber is full. There is a specific procedure to follow when a new drainage system is connected to a client's chest tube. A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action? Check the client. Rationale: If a monitor alarms sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. The other options would be appropriate once the nurse has checked the client. A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action? Place the client in high-Fowler's position. Rationale: The first nursing action is to place the client in a position that aids in respiration, which would be sitting bolt upright or in high-Fowler's position. Other nursing actions follow in rapid sequence and include monitoring vital signs and administering bronchodilators and oxygen (but at levels of 2 to 5 L/min or 24% to 28% by Ventimask). Insertion of an intravenous line and ongoing monitoring of respiratory status are also indicated. The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first? Inspect chest tube connections. Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear in the pulmonary pleura, which requires primary health care provider intervention. Although the other options are correct, they should be performed after initial attempts to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's symptoms should resolve. The nurse would also notify the registered nurse. A client with pneumonia is admitted to the hospital, and the primary health care provider writes prescriptions for the client. Which prescription should the nurse complete first? Obtain a culture and sensitivity of sputum. Rationale: A culture and sensitivity should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options 1, 2, and 4 are standard parts of therapy for pneumonia, but sputum is collected first. The nurse is caring for a client with fractured ribs. Which statement indicates a need for further teaching? "My ribs will be healed in a month." Rationale: Rib fractures heal in 6 weeks. Pain typically persists for 5 to 7 days. After medications are given, the client should be provided a calm environment and encouraged to rest. After rib fractures, instruct the client to support the fractured ribs while deep breathing and coughing. The nurse is assisting in admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse plans to admit the client to which type of room? Venting to the outside, six air exchanges per hour, and ultraviolet light Rationale: The client is admitted to a private room that has at least six air exchanges per hour and negative pressure in relation to surrounding areas. The room should be vented to the outside and should have ultraviolet lights installed. The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). Which are signs and symptoms of tuberculosis? Select all that apply. 2. Night sweats 4. Mucopurulent sputum 5. Afternoon low grade fever Rationale: The client with tuberculosis may report symptoms that have been present for weeks or even months. The symptoms may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever in the afternoon, and cough with mucoid or blood-streaked sputum. The cough is often persistent. The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis? pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L Rationale: In metabolic alkalosis, the pH is elevated along with the bicarbonate level. Option 4 is the only option that reflects these values. The nurse is collecting respiratory data from an adult client and is auscultating for normal breath sounds. The nurse should expect to hear bronchial breath sounds in which anatomical area? Refer to figure. A Rationale: There are three types of normal breath sounds in the adult and older child. These include bronchial (sometimes called "tracheal" or "tubular"), bronchovesicular, and vesicular sounds. Bronchial breath sounds are heard over the trachea and larynx. Bronchovesicular breath sounds are heard over the major bronchi. Vesicular breath sounds are heard over peripheral lung fields where the air enters the alveoli. The nurse is preparing to perform chest physiotherapy (CPT) on a client. In performing postural drainage, which statement is incorrect? Breathe in a fast-paced pattern. Rationale: The goal of chest physiotherapy is to mobilize secretions for improved respiratory function. The nurse must determine which areas of the lungs should be targeted for this technique. The client should be instructed to breathe slowly and deeply throughout the procedure. The client should not sit up between position changes. Perform postural drainage before meals or tube feedings. It may be ordered after respiratory treatments with bronchodilators. After postural drainage is completed, good mouth care—including brushing the teeth and using a refreshing mouthwash— should be performed. A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client? Use a picture or word board. Rationale: The client with a tracheostomy in place cannot speak. The nurse devises an alternative communication system with the client. Use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. A pad and pencil is an acceptable alternative but requires more client effort and more time. The use of hand signals may not be a reliable method because it may not meet all needs and is subject to misinterpretation. The family does not need to bear the burden of communicating the client's needs, and they may not understand them either. The nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which intervention to prevent the client from obstructing the airway with the teeth? Oral airway Rationale: An oral airway may be used to keep the client from biting down, occluding an orotracheal tube. A nasal airway is not used in conjunction with an oral endotracheal tube. A padded tongue blade or a bite stick may be used initially to open the mouth for easier insertion of an oral airway. client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation? Directly observed therapy Rationale: Tuberculosis is a highly communicable disease that is reportable to local public health departments. Each of these agencies has regulations that may be enforced to ensure compliance with tuberculosis therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day. Which are signs and symptoms characteristic of emphysema? Select all that apply. 1. Cyanosis 3. Weight loss 4. Barrel chest 5. Shortness of breath 6. Decreased lung sounds Rationale: The client with emphysema has a barrel chest, weight loss, and decreased lung sounds. Late signs and symptoms include shortness of breath and cyanosis. Wheezing is absent but is noted in other conditions such as asthma. A client is at risk of developing a pulmonary embolism. The nurse monitors for which initial sign/symptom? Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope. The nurse is talking with a client who is going to have a radical neck dissection and total laryngectomy. Which client statement indicates a need for further teaching concerning postoperative management? "I will require a lot of pain med after surgery." Rationale: The client who is going to have a radical neck dissection and total laryngectomy needs to support the head when getting up to prevent stress on the suture line. Clients will have less pain than expected because many nerves have been cut, and there will be areas of permanent numbness. Although the client will initially be on tube feeding, the client will gradually be able to eat oral fluids and food. The client will later determine options to restore some form of speech. A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder? Increased intracranial pressure Rationale: Carbon dioxide acts as a vasodilator to cerebral blood vessels. With a sufficient rise in carbon dioxide, the client may suffer increased intracranial pressure, which is reflected initially as papilledema and dilated conjunctival blood vessels. Options 1, 2, and 3 are not complications. A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which manifestation of histoplasmosis? Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There also may be enlargement of the client's lymph nodes, liver, and spleen. A client who has just suffered a flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action? Notify the registered nurse. Rationale: The nurse would notify the registered nurse who would then contact the primary health care provider. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This will lead to severe pain and dyspnea and can affect circulatory hemodynamics. A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder? Pao2 49 mm Hg, Paco2 52 mm Hg Rationale: Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnia, Paco2 elevations of 5 mm Hg or more from the client's baseline are considered diagnostic. The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse sign/symptom indicating acute pulmonary edema? Frothy sputum Rationale: The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep breathing is expected and managed with analgesics. The client with pneumonectomy usually does not have a chest tube. The nurse is assessing a client who has frequent episodes of asthma. Which assessment finding is most closely associated with asthma? Bilateral wheezing Rationale: Wheezing is the symptom most associated with asthma, a reactive airway disease. Fine rhonchi; rhonchi that clear with a cough; and pink, frothy sputum are not associated with asthma. The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene? The student suctions the client's tracheotomy tube for 15 seconds. Rationale: Applying suction longer than 10 seconds can cause oxygen deprivation. The client should be placed into semi-Fowler's position to optimize breathing. Wall suction pressure of 100 mm Hg is usually recommended to prevent tissue disruption. The student is expected to insert the catheter without suction applied to maintain oxygen delivery and to prevent damage to the mucosa. A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which data accurately indicate effectiveness of the treatments prescribed for this problem? Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg. Rationale: Demonstration of adequate ventilation can only be accurately evaluated when both Po2 and Pco2 levels are known. The other options do not indicate adequate gas exchange. Remember that oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin. Which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis? "I will need surgery to drain my sinuses." Rationale: The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of hot wet packs over the affected sinuses to promote comfort and help resolve the infection. Large amounts of fluids are important to help liquefy secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. Surgery may be performed to improve drainage in chronic conditions if other measures are not helpful, but it is not usually a treatment measure for acute sinusitis. A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention should the client be encouraged to perform? Avoid foods that are highly seasoned. Rationale: The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Milk and milk products are avoided because they tend to increase mucous production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to drink 2000 to 3000 mL of fluid daily unless contraindicated. A client arrives in the emergency department with a bloody nose. Which is the initial nursing action? Assist the client to a sitting position with the head tilted slightly forward. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied along with a topical vasoconstrictive medication. The primary health care provider may also prescribe packing to the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood to reduce the risk of nausea and vomiting. The nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a Pao2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client? Ineffective gas exchange Rationale: Restlessness and low Pao2 are hallmark signs of ineffective oxygen exchange. Airway obstruction and aspiration are not problems that are specifically associated with existing pneumonia. Although many clients with pneumonia experience fatigue, this is not the priority problem. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis? Po2 of 60 mm Hg and Pco2 of 50 mm Hg Rationale: During an acute exacerbation, the arterial blood gases deteriorate with decreasing Po2 levels and increasing Pco2 levels. In the early stages of chronic obstructive pulmonary disease, arterial blood gases demonstrate mild to moderate hypoxemia with the Po2 in the high 60s to high 70s (mm Hg) and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result. The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination? The system is functioning as expected. Rationale: Fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate an air leak, kinking, or that the lung has reexpanded. The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding? This finding requires further data collection. Rationale: Within the first 2 hours following surgery, 100 to 300 mL of drainage is expected. An amount of 700 mL is excessive and indicates that hemorrhage may be occurring, and the client requires further data collection. The primary health care provider should be notified. Options 2, 3, and 4 are incorrect. The nurse is assigned to assist in caring for a client with a chest tube drainage system. Which interventions should the nurse implement? Select all that apply. 2. Check for subcutaneous emphysema. 4. Check to see that the chest tube drainage is fluctuating. 5. Maintain chest tube drainage container below the client's chest. Rationale: Remember that the pleural cavity is an airtight compartment. The apparatus and all connections must remain airtight at all times. Do not allow the tubing to become kinked or obstructed by the weight of the client. Never pin the tubing to the bedclothes. Do not empty chest tube drainage containers. The system must remain closed. The system operates by gravity and must remain below the client's chest level at all times. Fluid in the chamber should fluctuate with inhalation and exhalation. A "puffed-up" appearance of the client's chest or neck could be subcutaneous emphysema. A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action? Notify the registered nurse. Rationale: Immediately following laryngectomy, there is a small amount of bleeding from the tracheostomy that resolves within the first few hours. Bleeding 24 hours after the surgery may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potentially life- threatening situation, and the registered nurse needs to be notified who will then contact the primary health care provider. Although the other options may be appropriate, they do not address the urgency of the problem. Failure to notify the primary health care provider in a timely fashion places the client at risk. The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observations are consistent with the need for suctioning? Select all that apply. 1. Restlessness 2. Gurgling sounds with respiration 3. Presence of congestion in the lungs 4. Increased pulse and respiratory rates Rationale: Indications for suctioning include moist, wet respirations; restlessness; congestion on auscultation of the lungs; visible mucus bubbling in the ETT; increased pulse and respiratory rates; and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system. The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? Select all that apply. 2. Rest 3. Local heat 4. Analgesics Rationale: Common therapies for fractured ribs include rest, analgesics, and the local application of heat that speeds the resolution of inflammation. Ice is not effective 48 hours after injury, and oxygen may not be necessary. Analgesics that cause respiratory depression are avoided. A client experiencing a pleural effusion had a thoracentesis. Analysis of the extracted fluid revealed a high red blood cell count. The nurse interprets that this result is consistent with which diagnosis? Trauma Rationale: Pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, HF, liver or renal failure, malignancy, or inflammatory processes. The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? Select all that apply. 2. Early onset cough 4. Purulent mucous production 5. Mild episodes of dyspnea Rationale: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucous production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucous production, minimal weight loss, and milder episodes of dyspnea. A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the primary health care provider for which prescription? Use of a spacer Rationale: For a client with arthritis or other conditions that limit the use of the hands, the use of a spacer may prove beneficial. A spacer allows the medication to be delivered deep into pulmonary tissues even if the client has difficulty with coordination. MDIs may be difficult to use because they require coordination and adequate hand motion to hold the canister at the proper distance (1½ to 2 inches from the mouth), depress the canister, and inhale. A spacer is especially useful for clients who are older or who have difficulty using an MDI. The other options are incorrect. The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply. 1. Loss of smell 2. Chronic cough 3. Nasal stuffiness Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. A clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendations by the nurse are therapeutic? Select all that apply. 1. Get plenty of rest. 2. Take antipyretics for fever. 3. Increase intake of liquids. Rationale: Immunization against influenza is a prophylactic measure and is not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics also may be used for symptom management. Carbohydrates are not necessarily more important than other elements of a healthy diet. The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? Abdominal distention Rationale: Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may indicate an obstruction of some sort or the presence of bronchoconstriction. The nurse is assisting in preparing a list of instructions for an adult client who is being discharged following a tonsillectomy. Which instructions should the nurse include in the list? Select all that apply. 1. Avoid hot fluids. 2. Avoid rough foods. 4. Rest for the next 24 hours. Rationale: Following tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products are avoided because they may cause the client to cough, which can hurt the surgical site. Rough foods and snacks such as raw fruits or vegetables should be avoided for 10 days to protect the scab that forms over the operative site and to prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity. The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client? Select all that apply. 1. Protect the stoma from water. 2. Soaps should be avoided near the stoma. 3. Wash the stoma daily using a washcloth. 5. Apply a thin layer of petroleum jelly to the skin surrounding the stoma. Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water. The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan which as a final measure to determine correct tube placement? Verify placement by a chest x-ray. Rationale: The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement. The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? The client is breathing through the nose. Rationale: Incentive spirometry is not effective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results. A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions should be done? Select all that apply. 2. Administer humidified oxygen. 3. Instruct on the use of the incentive spirometer. 4. Monitor vital signs and pulse oximetry frequently. Rationale: A client with a pneumonectomy can be turned slightly and supported with a pillow, but complete lateral positioning is contraindicated because of pressure on the bronchial stump or shifting of mediastinal contents. In addition, the surgeon's prescription for positioning is always checked and followed. The client needs to receive oxygen and use an incentive spirometer to prevent atelectasis in the remaining lung. Vital signs and pulse oximetry need to be monitored frequently. The client should not be placed in respiratory isolation to prevent infection; this is unnecessary. The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique? The client's exhalation is twice as long as inhalation. Rationale: Prolonging the time for exhaling reduces air trapping because of airway narrowing or collapse in chronic obstructive pulmonary disease. Tightening the abdominal muscles aids in expelling air. Exhaling through pursed lips increases the intraluminal pressure and prevents the airway from collapsing. The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply. 1. Elastoplast tape 3. Sterile 4 × 4 gauze pads 4. Povidone-iodine solution 5. Petrolatum (Vaseline) gauze Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of sterile 4 × 4 gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine solution may be used to clean the insertion site before the insertion of the chest tube. Kerlix dressing, which is a wrap-type dressing used to wrap and hold dressings in place is not used on the chest; these dressing types are used commonly to wrap dressings placed on the arms or legs. While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? Knifelike pain that worsens on inspiration Rationale: A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is a result of the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat. The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply. 1. Hemoptysis 4. A sensation of a "lump" in the throat 5. Hoarseness lasting more than 3 weeks Rationale: Hemoptysis, a sensation of a lump in the throat, and hoarseness lasting more than 3 weeks are common signs and symptoms of laryngeal cancer. A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate? The tube may be occluded. Rationale: Chest tube drainage in the first 24 hours following thoracic surgery may total 500 to 1000 mL. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further evaluation. Options 1, 3, and 4 are incorrect interpretations. The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub that was auscultated the previous day. How should this finding be interpreted? Pleural fluid has accumulated in the inflamed area. Rationale: Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 3, and 4 are incorrect interpretations. The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement? Shortness of breath and tracheal deviation Rationale: Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal deviation and impedance of venous return to the heart. It may also be the result of other problems such as a failing heart. oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status? Instruct the client not to move the sensor. Rationale: The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, toe, or earlobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is saturated with oxygen (Sao2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client's finger. If values fall below preset norms (usually 90%), the client should be instructed to deep breathe if this is appropriate. The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply. 3. Headache, especially in the morning 4. Elevated white blood cell (WBC) count 5. Feeling of heaviness over affected areas Rationale: Signs and symptoms of sinusitis include a feeling of heaviness over the affected areas. This can feel like a toothache if maxillary sinusitis or a headache, especially in the morning, for frontal sinusitis. Nasal drainage can become purulent. The white blood count is elevated. A high fever and nuchal rigidity are signs and symptoms of meningitis, which is a possible complication of sinusitis. A client enters the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action? Have the client sit down, lean forward, and apply pressure to the nose. Rationale: Sitting the client with the head forward and with pressure applied to the nose is the most effective way to initially control bleeding. Treatment is always directed at a conservative measure first. Placing the client in the semi-Fowler's position causes the client to swallow blood. Preparing a nasal balloon for insertion is invasive and used only when all other efforts have failed. Biting on a tongue blade does not cause cessation of nasal bleeding. A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit? Nasal obstruction Rationale: Nasal obstruction is the most common symptom associated with a nasal tumor because the tumor occupies space in the nasal area. Bleeding (epistaxis) may occur but is not a primary sign. Headache and a runny nose are not compatible with the clinical picture of a client with a nasal tumor. The nurse is caring for a client with laryngitis. Which interventions should the nurse implement? Select all that apply. 1. Discourage smoking. 2. Use a room humidifier. 5. Use lozenges that contain a topical anesthetic agent. Rationale: Smoking irritates the throat, so the client is discouraged from smoking. A humidifier will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will decrease throat discomfort. Voice rest means not talking at all, even whispering. There should be a sign on the intercom indicating voice rest and going to the client's room. The nurse is assisting a client who underwent radical neck surgery to get out of bed. How does the nurse provide support to this client who is afraid to move the head? The nurse places a hand behind the client's head. Rationale: The nurse provides the most support to the surgical site by placing a hand behind the client's head. Options 3 and 4 involve little assistance or support by the nurse. Option 1 is unnecessary and could occlude a tracheostomy if one is in place. A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour? Refrigerate the specimen. Rationale: Refrigeration will stabilize the culture and prevent the growth of additional bacteria. Options 2, 3, and 4 are unnecessary. A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays? The protective mechanism of the nose may be damaged. Rationale: The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers but not nasal sprays. Nosebleeds are uncommon. The client should not double-dose medications to increase their effect. The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection? Chills and night sweats Rationale: The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status? Respiratory rate of 18 breaths per minute Rationale: An airway problem could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. An oxygen saturation of 89% is less than optimal. The nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How should the nurse interpret these noises? Wheezes Rationale: Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus that accumulates in the air passages. A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective? Breath sounds are now clear. Rationale: Clear breath sounds are the most accurate indicator of the effectiveness of a suctioning procedure. Options 3 and 4 are incorrect because they are less precise. Option 2 is incorrect because the need for suctioning may be influenced by factors other than the effectiveness of previous suctioning. These other factors could include improvement of underlying respiratory condition, fluid status, and effectiveness of cough. A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the primary health care provider whether this process should be delayed temporarily based on administration of which medication to the client in the last hour? Lorazepam Rationale: Antianxiety medications (such as lorazepam) and opioid analgesics are used cautiously or withheld whenever possible in the client being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The other medications do not interfere with the respiratory drive a A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening? Tracheal deviation to the right Rationale: A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration even with a milder pneumothorax. The increased intrathoracic pressure causes the blood pressure to fall, not rise. A respiratory rate of 18 breaths per minute is within the normal range. A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected? Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience significant clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing. The nurse is preparing a plan of care for the client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse should avoid which positioning? On the right side Rationale: Following a wedge resection, the client should not be placed on the operative side. Lying on the operative side hinders expansion of remaining lung tissue and may accentuate perfusion of poorly ventilated tissue. This further impedes normal gas exchange. In addition, complete lateral turning may be contraindicated. The surgeon's prescriptions for positioning after this surgical procedure are always followed. The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations? Neurological disorders Rationale: Biot's respirations are irregular respirations of varying depth and periods of apnea seen in neurological disorders. Emphysema causes obstructive breathing, rising end-expiratory level with forced rapid breathing. Renal failure can cause Kussmaul respirations, which are rapid and deep. Severe anxiety causes hyperventilation. Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply. 2. Position on the side until fully recovered 3. Encouraging coughing and deep breathing 4. Monitoring pulse oximetry readings frequently 5. Encouraging the use of an incentive spirometer Rationale: Monitoring and maintaining a patent airway is a nursing responsibility. The nurse should monitor oxygen saturation closely and administer oxygen as prescribed. The use of an incentive spirometer is especially helpful to prevent atelectasis and hypoventilation. Unless contraindicated, the client should be positioned on the side or with the head turned to the side to prevent aspiration until fully recovered, alert, and with the gag reflex intact. The client is encouraged to deep breathe and cough every 2 hours to prevent atelectasis. The client should be repositioned every 2 hours, which changes the distribution of gas and blood flow in the lungs and helps move secretions. A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation should the nurse make? The client should be repeating the sequence 10 to 20 times in each session. Rationale: Incentive spirometer devices use a concept of sustained maximal inspiration. Each device has a means of setting an inspiratory goal. Correct use requires a spontaneous, slow, voluntary, deep breath. When full inhalation is reached, the breath is held for at least 3 seconds. This sequence is repeated 10 to 20 times an hour. Incentive spirometer exercises are most effective when used every hour while the client is awake. A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note? Po2 of 60 mm Hg and Pco2 of 50 mm Hg Rationale: During an acute exacerbation of COPD, the arterial blood gases deteriorate with a decreasing Po2 and an increasing Pco2. In the early stages of COPD, arterial blood gases demonstrate a mild to moderate hypoxemia, with the Po2 in the high 60s to high 70s and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result. The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? Coughing occurs with suctioning. Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the primary health care provider immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure. A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken? The client plans to eat the largest meal of the day at a time when hungry. Rationale: The client is taught to plan the largest meal of the day at a time when the client is most likely to be hungry. It is also beneficial to eat four to six small meals per day if needed. The client avoids dry foods, which are hard to chew and swallow. The client also avoids milk and chocolate, which have a tendency to thicken saliva and secretions. Finally, the client should avoid the use of caffeine, which contributes to dehydration by promoting diuresis. A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation? Absence of breath sounds in the right upper lobe Rationale: Pneumothorax and bleeding are possible complications of this procedure. The client is observed for signs of respiratory difficulty such as dyspnea, change in breath sounds, vital signs, pallor, and diaphoresis. Observation of the sputum for traces of blood or hemoptysis also is indicated. The absence of breath sounds in the right upper lobe indicates a potential pneumothorax. The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning? Breath sounds are clear Rationale: The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps determine if the respiratory tract is clear of secretions. In addition, breath sounds must be auscultated before every suctioning procedure. Options 1, 3, and 4 do not determine the effectiveness of suctioning. A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom? Breath sounds greater on the right than the left Rationale: Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the primary health care provider. A weak cough and gag reflex 1 hour postprocedure is an expected finding because of residual effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and an oxygen saturation of 95% are acceptable measurements. The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply. 3. Hypotension 5. Use of peripheral vasoconstrictors Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low. The primary health care provider has prescribed amantadine for a client admitted to the hospital for hip replacement surgery. The nurse recognizes that this medication was prescribed because the client's history showed recent exposure to which? Type A influenza Rationale: Antiviral medications may be used in specific client populations. If a person is known to be at high risk for influenza and has been exposed to type A influenza, the provider may choose to provide prophylaxis with an antiviral agent such as amantadine. Amantadine would not be prescribed to prevent bronchitis, pneumonia or tuberculosis. A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? There is a leak in the system that requires immediate investigation and correction. Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates that a leak exists somewhere in the system and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action that may include notifying the primary health care provider. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber but not the water seal chamber. A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply. 1. Mental changes 2. Cardiac irregularities 3. Cherry-red skin color Rationale: Carbon monoxide poisoning results from a buildup of carboxyhemoglobin. Evaluate for early signs and symptoms of carbon monoxide poisoning, which include headache and shortness of breath with mild exertion. Dizziness, nausea, vomiting, and mental changes appear next. As the amount of carbon monoxide in the bloodstream rises, the victim loses consciousness and develops cardiac and respiratory irregularities. A victim usually dies when the carbon monoxide bound with hemoglobin exceeds 70%. Although a cherry-red skin color is a clear indicator of carbon monoxide poisoning, skin color is often found to be pale or bluish with reddish mucous membranes. In carbon monoxide poisoning, the readings of pulse oximetry and the values of arterial blood gases can appear normal despite significant toxic exposure. The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB? Residents of a long-term care facility Rationale: Residents of long-term care facilities are considered high-risk candidates for TB. Children younger than 4 years of age also are considered a high-risk group. Persons admitted for day surgery are not high-risk candidates. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam) are considered high risk, but those from Australia are not. The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation? The behavior is likely the result of hypoxia. Rationale: The client with carbon monoxide poisoning may appear intoxicated. This is the end result of hypoxia on the central nervous system (CNS). With carbon monoxide poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly bound carbon monoxide. Because cerebral tissue has a critical need for oxygen, sustained hypoxia may yield this typical finding. For this reason, options 2, 3, and 4 are incorrect interpretations. A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation? Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out Rationale: With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell forcing intracellular potassium out. This is an expected finding in this situation. Options 1, 2, and 3 are incorrect interpretations. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take? Monitor vital signs and discontinue attempts at suctioning until the client is stabilized. Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm while suctioning, the nurse must discontinue suctioning attempts until the client is stabilized. It is also important to monitor vital signs and pulse oximetry and preoxygenate the client for any repeated suctioning attempts. If the client's condition continues to deteriorate, then the respiratory department and primary health care provider may need to be notified. The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign should the nurse emphasize as one that indicates severe airway obstruction? Cyanosis Rationale: Signs of severe airway obstruction include cyanosis, poor air exchange, increased breathing difficulty, a silent cough, or inability to speak or breathe. Options 2, 3, and 4 are incorrect and may be signs of mild respiratory distress that would not require immediate intervention. A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care? Instruct the client to reposition himself. Rationale: Therapy for COPD usually includes glucocorticoids that carry a high risk of complications such as muscle and bone wasting, fragile skin, impaired immune functioning, and fluid retention, so the nurse must restore some client strength before attempting to get the client out of the bed. Because the client is likely to be weak from bed rest and lack of activity during mechanical ventilation and treatment, the nurse establishes outcomes for the client including restoration of pulmonary, cardiovascular, and musculoskeletal functioning to return to baseline functioning. To begin safely, the nurse instructs the client to reposition himself in bed to exert force on muscles and bones helping to reverse the tissue loss incurred during bed rest. The nurse initially positions a client with COPD at 45 degrees or higher until the client can tolerate a lower position and still maintain adequate oxygenation. Self-repositioning can be followed with dangling at the bedside and sitting in the chair before attempting ambulation. Active flexing and extending ankles is very important to prevent a thromboembolic event related to bed rest, but this activity will not adequately restore strength. The nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from reentering the pleural space? Refer to figure. B Rationale: To prevent atmospheric air from reentering the client's pleural space, the nurse needs to fill the water seal chamber to the level prescribed by the manufacturer, usually 2 cm. This is the minimum amount of fluid needed to prevent atmospheric air from reentering the pleural space. Therefore, options 1, 3, and 4 are incorrect. Option 1 identifies the suction control chamber. Options 3 and 4 identify the collection chamber. The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)? A client with pancreatitis and gram-negative sepsis Rationale: The client with pancreatitis and gram-negative sepsis is at greatest risk of developing ARDS because of the presence of two risk factors for its development. Although the client with blunt chest trauma is also at risk, those who have multiple risk factors have a three to four times greater incidence for development of ARDS. Massive blood transfusion is a risk factor for ARDS; however, this client has received only 1 unit. Pulmonary edema after myocardial infarction occurs when increased pulmonary capillary hydrostatic pressure causes flooding of the pulmonary interstitial spaces and then the alveoli. The pulmonary edema that occurs in ARDS is due to damage to pulmonary vasculature resulting in increased pulmonary capillary permeability. The nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Refer to audio.) The nurse should interpret this sound to be indicative of which breath sound? Bronchial breath sounds Rationale: The sound that the nurse hears is a bronchial breath sound. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phase. Bronchial breath sounds normally are heard only over the manubrium. When they are heard over the periphery of the lung, they indicate abnormal sound transmission because of consolidation of lung tissue as in pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Refer to audio.) The nurse determines that these breath sounds usually result from which cause? Opening of small airways that contain fluid Rationale: The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid. Crackles are usually heard during inspiration, and do not clear with a cough. They resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial low-pitched coarse rubbing or grating sound) is heard when the pleural surfaces are inflamed. Passage of air through a narrowed airway is associated with wheezes (a high-pitched musical sound similar to a squeak). In which area of the chest should the nurse expect to auscultate this breath sound? (Refer to audio.) Over the peripheral lung fields Rationale: Breath sounds are noises resulting from the transmission of vibrations produced by the movement of air in the respiratory passages. Normal breath sounds include bronchovesicular sounds, vesicular breath sounds, and bronchial breath sounds. The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling, and the inspiration phase is longer than the expiration phase. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The inspiration and expiration phases are equal. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phase. Bronchial breath sounds are heard normally over the manubrium. The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer? Cough Rationale: Cough is the most frequent early sign of lung cancer that begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Wheezing and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature. A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? Lowering the head of the bed to a flat position Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, contacts the registered nurse immediately who will then call the primary health care provider immediately. Which diagnostic tests indicate active tuberculosis? Select all that apply. 1. Chest x-ray 3. Gastric analysis washings 4. Sputum smear and culture Rationale: Active tuberculosis is diagnosed by a chest x-ray, sputum smear, and sputum culture. A diagnosis of active TB is established when the tubercle bacillus has been found in the sputum or gastric washings. Interferon gamma release assays (IGRA) is a diagnostic aid that measures a component of cell-mediated immune reactivity to M. tuberculosis much like the tuberculin skin testing. These test results indicate a need for further evaluation. The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which action as the best strategy to assist the client in coping with the disease? Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale: A primary role of the nurse in working with the client with tuberculosis is to teach the client about medication therapy. The anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids) and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis? High-grade fever Rationale: The client with TB usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweating (which may occur at night), and a low-grade fever. A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse should provide which explanation for these symptoms? Expected and the client should very gradually increase activity as tolerated Rationale: The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure? Left side-lying with the head of the bed elevated at 45 degrees Rationale: To facilitate removal of fluid from the chest wall, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table with his or her feet supported on a stool. The other position is lying in bed on the unaffected side with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area where it can be easily removed with thoracentesis. The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing? Lying on his or her back in low-Fowler's position Rationale: The client should use the positions outlined in options 1, 2, and 3. These positions allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client should not lie on his or her back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control. A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position? Right lateral Rationale: The client who has a pneumonectomy should not be positioned in the extreme lateral position. This could cause mediastinal shift and compression of remaining lung tissue. The other positions do not pose this risk for the client. A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse should plan to take which actions? Select all that apply. 1. Check vital signs. 3. Notify the registered nurse. 4. Begin low-flow oxygen therapy. Rationale: Initial care for a client who might be experiencing a PE is to remain calm, stay with the client, raise the head of the bed to a high-Fowler's position, begin low-flow O2 therapy, check vital signs, notify the registered nurse and primary health care provider of the client's symptoms, start a peripheral intravenous line if one is not already established, and assist to administer heparin when it is prescribed. A low-Fowler's position would not be used initially and heparin is administered in the initial stage of a suspected pulmonary embolism. A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action should the nurse take? Reinforce the dressing. Rationale: Chest tube dressings may be reinforced but are not changed unless prescribed by the surgeon. Dressings are kept dry and occlusive. A small amount of serosanguineous drainage right after surgery can be expected, so the surgeon would not be notified. Just documenting the findings does not ensure a dry dressing. A primary health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the primary health care provider asks the client to do which action? Perform the Valsalva maneuver. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off and the wound heals in less than a week. Therefore, options 1, 2, and 3 are incorrect. The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)? Stridor Rationale: The nurse reports the presence of stridor to the RN immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. A respiratory rate of 26 breaths per minute and congestion are abnormal, but additional data are needed to determine if these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time. The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube? "To allow for reexpansion of the lung." Rationale: A chest tube may be inserted after a pneumothorax and connected to water-seal drainage to remove the air and allow reexpansion of the lung. It does not lessen discomfort, prevent further damage to the lung, or help prevent lung infections. A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason? To expel mucus from the airways Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client. A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty? It could decrease the client's oxygen-based respiratory drive. Rationale: Normally, respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD usually cannot increase oxygen levels independently because it could deplete the respiratory drive and lead to respiratory failure. Physician prescriptions are always followed. The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location? Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. To check breath sounds in a client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The other options are incorrect. The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? Places the stethoscope on the client's gown Rationale: To listen to breath sounds, the stethoscope always is placed directly on the client's skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed before use. The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse should perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed. All options must be used. 1. Obtain and label a sterile container. 2. Have the client brush teeth and rinse mouth with water. 3. Have the client take several deep breaths before coughing. 4. Have the client expectorate sputum (not saliva) into sterile container. 5. end the specimen immediately to the laboratory. 6. Administer the prescribed antibiotics. Rationale: Once the nurse notes the prescription to obtain a sputum specimen for culture and sensitivity, the nurse should obtain and label a sterile specimen container. The client is then instructed to brush teeth and rinse mouth with water to decrease contamination of the sputum. Antiseptic mouth wash should not be used. The client should then take several deep breaths before coughing. The client should then expectorate sputum (not saliva) into the sterile container. The collected specimen should be taken immediately to the laboratory. After the specimen is collected, then antibiotics can be started. The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer? Nonproductive hacking cough Rationale: Cough is the most frequent early symptom of lung cancer; it begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature. The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action should the nurse do first? Check the client. Rationale: For a client receiving mechanical ventilation, always check the client first and then check the ventilator. A resuscitation bag should be available at the bedside for all clients receiving mechanical ventilation. If the cause of the alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected. The nurse needs to determine if the respiratory therapist or rapid response team needs to be called. The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action? Stop the procedure and oxygenate the client. Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client. The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign of acute respiratory distress syndrome? Increased respiratory rate Rationale: The first sign of ARDS is usually increased respiratory rate. Auscultation of the lungs may reveal fine crackles. The client may be restless, agitated, and confused. The pulse rate increases and a cough may be present. These early signs are followed by progressively worsening dyspnea with retractions, cyanosis, and diaphoresis. Diffuse crackles and rhonchi may be heard on auscultation. The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? Arterial Pao2 of 48 Rationale: The most characteristic sign of ARDS is increasing hypoxemia with a Pao2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience? Dyspnea The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status? Instruct the patient to not move sensor The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply. 2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds." Rationale: After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and damage the lens implant. The client should not sleep on the side of the body that was operated on. The client may resume activities such as sitting upright at a table or sitting in a recliner with the feet elevated. The client should not lift anything heavier than 10 lbs. The client should not perform activities that would increase the pressure within the eye, such as bending over to tie shoes or performing pushups. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? Stand in front of the client. Rationale: The nurse should ensure that the hearing-impaired client can see the nurse when the nurse is speaking by providing adequate lighting and standing in front of the client. The nurse should enunciate words clearly, but not exaggerate lip movements. If the client is profoundly hearing impaired and uses signing, a sign-language interpreter should be obtained. If a client cannot understand by reading lips, the nurse should try using gestures, pantomiming, or writing notes. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? Use low-pitched tones. Rationale: Presbycusis refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client. Speaking loudly, softly, or slowly is not helpful. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 3. To take acetaminophen for minor eye discomfort 4. To place an eye shield on the surgical eye at bedtime 6. To contact the surgeon if a decrease in visual acuity occurs Rationale: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over. The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? Rationale: Eye medications may need to be administered for the rest of your life. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications may need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure. Option 3 is not necessary. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? A sense of a curtain falling across the field of vision Rationale: A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Options 1 and 3 are not specifically associated with a detached retina. The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 2. Vision may be cloudy 5. Complaints of a burst of black spots or floaters Rationale: Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy. Options 1, 3, 4 and 6 are not specifically associated with bleeding as a result of detached retina. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? On bed rest in a semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? Apply ice to the affected eye. Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 3 and 4 will delay immediate treatment. After the application of ice, the PHCP would be notified. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? Irrigating the eye with sterile normal saline Rationale: Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? Report the finding to the registered nurse (RN). Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage. Options 1, 2, and 4 will delay necessary treatment. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? Pulling the pinna up and back Rationale: For an adult, the nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? Speak in a normal tone. Rationale: It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? Instillation of mineral oil or diluted alcohol Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. Options 1, 2, and 3 may be prescribed after the initial treatment if necessary and if inflammation or infection is a concern. The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition? A sensorineural hearing loss that occurs with aging Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions. A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo? Avoid sudden head movements. Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Watching television can increase the vertigo. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? Low-sodium diet Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific dietary prescriptions for this condition. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? Cardiovascular disease Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure. Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? Monitoring blood pressure Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication. The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action should the nurse plan to take? Warm the irrigating solution to 98° F (36.6° C). Rationale: Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist with the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture. In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication? To dilate the pupil of the operative eye Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis. The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform which action? Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption. The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform which action? Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption. Administer the eye drop first, followed by the eye ointment. The client is receiving an eye drop and an eye ointment to the right eye. Which action should the nurse take? Rationale: When an eye drop and an eye ointment is scheduled to be administered at the same time, the eye drop is administered first. Options 2, 3, and 4 are incorrect. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? Atropine sulfate Rationale: Options 1, 2, and 4 are miotic agents used to treat glaucoma. Option 3 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put on gloves. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. Rationale: To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication. A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? Acetylsalicylic acid Rationale: Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing PHCP so that the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have side effects that are potentially associated with hearing difficulties. Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? Atropine sulfate Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are ß-blockers. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose? "The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect. A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next? Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. Rationale: When a corneal donor dies, antibiotic eye drops may be prescribed and instilled. The eyes are closed and a small ice pack is placed on the closed eyes. The head of the bed is raised to 30 degrees to prevent edema. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 1 is incorrect because dry dressings are not applied. Some organ donation protocols indicate using normal saline-moistened gauze. Option 2 is not an immediate action. In addition, the client should have a signed donor card, living will, or an organ donor–identified driver's license stating his or her wishes. Additional legal documentation should not be required. Agency procedures regarding donor care should be followed. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? Smiling continuously during conversation Rationale: Hearing-impaired clients rely on visual cues to help them comprehend the conversation of others. Smiling continuously is the least helpful strategy, because the smile distorts the appearance of the mouth if the client is trying to read lips. When beginning the conversation, it helps to reduce background noise such as turning off or lowering the volume of the television. Facing the client and standing so there is light on the nurse's face are helpful strategies, because it assists the client with lip-reading. Taking care not to show frustration or annoyance with the client's impairment is also helpful to preserve their self-esteem. The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which signs and symptoms? Select all that apply. 1. Headache 2. Swelling directly behind the ear 5. Red and immobile tympanic membrane Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Signs and symptoms of mastoiditis include mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood cell (WBC) count. Thick, purulent drainage from the ear may be seen. A client is diagnosed with labyrinthitis. Which are signs and symptoms of labyrinthitis? Select all that apply. 1. Severe dizziness 4. Nausea and vomiting 5. Abnormal jerking movement of eyes Rationale: Signs and symptoms of labyrinthitis include vertigo, nausea, vomiting, headache, anorexia, nystagmus, and sensorineural hearing loss on the affected side. The client may also experience anorexia. The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. Which signs and symptoms should the nurse note? Select all that apply. 1. Tinnitus 4. Difficulty hearing voices of others 5. Bone conduction better than air conduction Rationale: Otosclerosis involves the formation of spongy bone in the capsule of the labyrinth of the ear often causing the auditory ossicles to become fixed and less able to vibrate when sound enters the ear. The primary symptom of otosclerosis is slowly progressive hearing loss in the absence of infection. In the early stages, the client may report tinnitus. The Rinne test reveals bone conduction to be greater than air conduction. The client often complains of difficulty hearing the voices of others, yet his own voice sounds unusually loud. In response to this, he may lower his voice to the point that he can scarcely be heard by others. The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching? "It is not necessary to restrict salt in my diet." Rationale: Management during remission of Ménière's disease includes diuretics to decrease the fluid and thereby decrease pressure in the endolymphatic system. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet may also be prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client's hearing; careful medical management helps achieve this in most clients with Ménière's disease. The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching? "I should turn the hearing aid off after removing it from my ear." Rationale: Nurses should have a basic knowledge of the care of a hearing aid to assist the client in its use. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent squealing feedback. The hearing aid should be turned off when not in use, and the client should keep an extra battery available at all times. The client should wash the ear mold frequently with mild soap and water using a pipe cleaner to cleanse the cannula. The client should not wear the hearing aid during an ear infection. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted? 15 mm Hg Rationale: Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between approximately 10 and 21 mm Hg are considered within the normal range; therefore, the other options are incorrect. The nurse is providing discharge instructions to a client who is postoperative cataract surgery on the left eye. Which statement indicates a need for further teaching? "If I have severe eye pain, I will take the narcotic pain pill that my doctor will prescribe for me." Rationale: After cataract surgery the most important thing is to prevent strain on the operative eye. The client should not lift more than 5 pounds. The client should protect the eye during the day with glasses and use sunglasses for outside wear. The client should wear a protective eye shield at night. A mild analgesic is usually ordered as needed. Postoperative clients with cataract surgery should not have severe pain. If a client complains of severe pain, the surgeon is notified. Severe pain may indicate hemorrhage or rising pressure within the eye. The nurse is reviewing the health record of a client diagnosed with a cataract. Which are signs and symptoms of cataract formation? Select all that apply. 2. Floaters in visual field 3. Difficulty in night vision 5. Decreased color perception Rationale: Signs and symptoms of a cataract include hazy, blurred, or double vision (diplopia), and floaters in visual field. There is increasing nearsightedness, complaints that colors are faded or appear yellowish or brownish, and difficulty with night vision. Uncomplicated cataracts are usually painless, but the client may have photophobia (intolerance of light). The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? On the nonoperative side Rationale: Postoperatively, cataract extraction clients should be positioned on their backs in a semi-Fowler's position or on the nonoperative side to prevent edema in the surgical site. The remaining positions are incorrect and will cause swelling at the surgical site. During the early postoperative stage, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. Which action should the nurse implement? Report the client's complaints. Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse and primary health care provider immediately. The remaining options are incorrect. The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching? "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." Rationale: After cataract surgery, a dressing is applied to the eye. It usually is removed later on the day of surgery or the following day. The client should not place a warm pack on the eye unless this is specifically prescribed because of the risk of infection and increased edema in the surgical area. The client is instructed to wear a metal or plastic eye shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. The client is instructed not to sleep on the side of the body that was operated on to prevent pressure and edema in the affected eye. The use of stool softeners is recommended to prevent constipation and straining. The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume? Sugar-free Jell-O Rationale: The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol. The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome? The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac. Rationale: Surgical treatment for Ménière's disease involves relief from accumulation of inner ear fluid in the endolymphatic sac. Procedures may be directed toward relief of pressure by the bony structures surrounding the sac or toward opening the sac and diverting the flow of endolymph by a shunt to the mastoid bone or to the subarachnoid space. The remaining options are procedures unrelated to Ménière's disease. The instructor is quizzing the student nurse concerning care of a visually impaired client. Which statement indicates a need for further teaching? "I will take the client's arm to lead while we are walking." Rationale: Measures to support the client with impaired vision and to prevent injury include announcing yourself when entering or leaving the room and speaking in a normal tone of voice. People tend to act as if those who cannot see also cannot hear, so a tendency exists to raise one's voice when talking to the visually impaired. Advise the client what to expect during procedures. Keep doors either open or closed so that the ambulatory client does not run into a partially closed door. To lead a blind person, have him or her take your arm. The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed? A mydriatic medication Rationale: A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. A miotic agent would constrict the pupil. An osmotic agent would act to decrease intraocular pressure. A thiazide diuretic would promote the excretion of body fluid. A thiazide diuretic is not likely to be prescribed for a client with a cataract. A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions? "I will wear my eye shield at night and my glasses during the day." Rationale: The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the same side of the body that underwent surgery. The client is not to lift more than 5 pounds. A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." Rationale: Vision loss to glaucoma is irreparable. The client needs to be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Options 1, 2, and 3 are incorrect. A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions, including watching television, may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the primary health care provider. The nurse should check for vision loss in a client with which condition? Diabetes mellitus Rationale: Elevated blood glucose levels can cause temporary blurred vision. Over time, permanent retinal changes can occur in clients with diabetes mellitus. Options 1, 2, and 4 are not conditions that cause eye damage. The nurse is assisting the primary health care provider with performing a Rinne tuning fork test on a client. The nurse expects that the steps of the testing will be performed in which priority order? Arrange the actions in the order that they would be performed. All options must be used. 1. Tap tuning fork to activate. 2. Place base of tuning fork on the mastoid bone. 3. Have client indicate when the sound disappears. 4. Move the tuning fork close to the ear canal. 5. Ask the client if he or she hears the sound and to indicate when the sound disappears. 6. Document whether bone or air conduction is better. Rationale: The Rinne test is performed to determine the client's ability to compare the perception of sounds through bone conduction and air conduction. For the Rinne test, the tuning fork is tapped on the hand to activate it. Then it is placed at the base of the tuning fork on the client's mastoid bone. If the vibration is conducted through the bone, the client hears a humming sound. When the sound is no longer heard by the client, the fork is moved so that the tines of the tuning fork are near but not touching the ear canal. The client is asked if he or she can hear the sound and, if so, to report when the sound disappears. This assesses the client's ability to hear sound waves conducted through the air. Normally, air conduction is better than bone conduction. Therefore, the client should be able to hear the sound transmitted through air even after it can no longer be heard through bone. This normal finding is recorded as "AC > BC" (air conduction is greater than bone conduction). If bone conduction is greater than air conduction, the client has a conductive hearing loss. The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions? "I will take stool softeners as prescribed by my doctor." Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery? Cranial nerve VII, facial nerve Rationale: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely reoccur following surgical removal. The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching? "I will become totally deaf if I don't follow instructions." Rationale: Ménière's disease is a disorder of the labyrinth of the inner ear. The hearing loss is unilateral, meaning that only one ear is affected. Biofeedback, self-hypnosis, and relaxation techniques may be recommended to help the client learn to live with Ménière's disease. A low-salt diet is sometimes prescribed for people with Ménière's disease. Caffeine, alcohol, chocolate, and nicotine may aggravate or trigger an attack. Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client? "A hearing aid may improve your hearing." Rationale: Clients with otosclerosis who do not desire surgery may have their hearing loss relieved by the use of a hearing aid. Options 2, 3, and 4 are inappropriate responses. The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss? "The attack leaves a hearing loss in the involved ear." Rationale: After the acute phase, remission occurs, but symptoms will recur with two or three acute attacks per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss varying from slight to complete. It takes several weeks before all symptoms subside after an attack leaving a loss of hearing in the involved ear. Options 1, 3, and 4 are incorrect. The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question? The administration of a vasoconstrictor Rationale: Medical interventions during the acute phase of Ménière's disease include using atropine or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bed rest during the acute attack and when allowed to be out of bed, will need assistance with walking, sitting, or standing. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching? "I need to avoid air travel for at least 6 months." Rationale: Following stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client is also instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If the client develops sudden hearing loss, fever, or severe persistent vertigo or dizziness, the primary health care provider should be notified. The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client? "You need to avoid air travel." Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients must be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients also must avoid rapidly moving the head, bouncing, and bending over for 3 weeks. A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client? "Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery." Rationale: A small amount of brownish or reddish drainage is normal for 24 to 48 hours following the surgery. Excessive drainage, especially clear fluid, should be reported immediately. Options 1, 2, and 3 are inaccurate instructions. The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which? Lower the voice pitch and face the client when speaking. Rationale: The nurse should lower the pitch of the voice and face the client while speaking. Lower tones are heard better with hearing loss, and facing the client allows the client to pick up visual cues from the nurse's face. Option 1 requires that the client and nurse understand sign language. Option 2 can be interpreted as hostility, whereas option 3 invades the client's personal space. A client has been diagnosed with cataracts. Which signs and symptoms should the nurse expect to note? Select all that apply. 2. Photophobia 3. Blurred vision 4. Decreased color perception Rationale: In addition to the blurred vision that is typical of opacity of the lens, with cataracts there may be decreased color perception. Uncomplicated cataracts are usually painless, but the client may have photophobia (intolerance of light). Progressive loss of peripheral vision is a sign of glaucoma. Flashes of colored light accompanied by showers of floaters are signs of retinal detachment. A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement? "There is no difficulty driving at dusk." Rationale: The client with impaired vision that may accompany glaucoma needs to take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and not driving at dusk or dawn. Satisfactory adjustment also is indicated by recognition of the need for ongoing eye examinations and the presence of a supportive family. A client reports to the health care clinic for an eye examination, and a diagnosis of primary open- angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? "Have you had difficulty with peripheral vision?" Rationale: Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes with an intraocular pressure of 40 to 50 mm Hg or higher. More severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration. These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow- angle glaucoma? Severe pain in and around eye Rationale: Narrow-angle, or acute, glaucoma is a medical emergency in which there is severe pain in the eye accompanied by the appearance of colored halos around lights, blurred vision, and pain in and around the eye. Nausea and vomiting may occur. Normal intraocular pressure is 10 to 21 mm Hg. The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? "You may return to work 1 or 2 days following the procedure." Rationale: Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 or 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored. The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching? "I can tie my shoelaces by bending over slowly." Rationale: Activities such as bending over or straining at stool will increase intraocular pressure. The client must be instructed to maintain a diet high in bulk and fiber and to consume a high intake of liquids, unless contraindicated, to prevent constipation and straining at stools. The client should tie shoelaces by bending the knee, raising the thigh, and bringing the foot within hand reach. Objects weighing 20 pounds or more can be moved by pushing the object on the floor using the feet or with a mechanical dolly. A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder should the nurse expect to be documented in the client's record? Select all that apply. 3. Increasing nearsightedness 4. Need for more light when reading 5. Painless progressive loss of vision Rationale: A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is painless progressive loss of vision in one or both eyes. Signs and symptoms of a cataract include hazy, blurred, or double vision (diplopia), and floaters in visual field. There is increasing nearsightedness, complaints that colors are faded or appear yellowish or brownish, and difficulty with night vision. There may be a need to increase lighting when reading. Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? "The prescriptive glasses will correct my visual field of sight." Rationale: Aphakia (absence of the lens of the eye) can be corrected by prescriptive glasses, contact lenses, or intraocular lenses. Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. Prescriptive glasses provide approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car. A client is brought to the ambulatory care department by the spouse 1 day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? "Maintain bed rest and patching of both eyes." Rationale: Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bed rest and bilateral eye patching for 2 to 5 days during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood. The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? "I can drink any liquids that I want to on the morning of the surgery." Rationale: The client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered, and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back but will grow slowly. Eye medications such as mydriatics, cycloplegics, or beta blockers may be administered before the surgical procedure. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptoms? Select all that apply. 1. Blurred central vision 2. Bending of straight lines 5. Inability to see color vividness Rationale: The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients may complain of visual distortion usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk. The client may be unable to see the vividness of colors or to see details. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? Apply a warm compress for 15 minutes 4 times daily. Rationale: Hordeolum is commonly known as a sty. Therapeutic management includes the application of a warm compress for 15 minutes 4 times daily and installation of an ophthalmic antibiotic ointment to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in bringing purulent contents to a head causing rupture with drainage. If a sty does not rupture spontaneously, it can be incised with a small sterile instrument by the primary health care provider. The client should be told not to press on or squeeze the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action? Notify the registered nurse. Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse who will notify the primary health care provider immediately. The other options are incorrect nursing actions. Ice is not applied to the surgical site unless prescribed. The client is not positioned on the operative side because of the risk of increasing intraocular edema from swelling. Although pain medication and an antiemetic may be prescribed, the client's symptoms indicate a serious complication requiring primary health care provider notification. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client? In semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as a penetrating injury from a BB pellet or indirectly from a blow to the forehead. The client is treated with bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. The positions identified in options 1, 2, and 4 will be harmful to the client. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action? Applies ice to the affected eye Rationale: Treatment for a contusion ideally begins at the time of injury and includes applying ice to the site. The client also should receive a thorough eye examination to rule out the presence of other eye injuries. An eye patch will not assist in treating this type of injury. Irrigating the eye with cool water may be implemented for injuries that involve a splash of an irritant into the eye. A client arrives in the emergency department with a foreign body in the eye. Which action should the nurse plan to perform first? Apply an eye patch to both eyes. Rationale: If a foreign body is in the eye, no attempt to remove it should be made. Both eyes should be patched to prevent further eye movement, until the primary health care provider can see the client. The eye should not be irrigated with any solution and no ointment should be applied. The primary health care provider may eventually check for corneal abrasions once the object is removed. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action? Irrigates the eye with copious amounts of sterile normal saline Rationale: Emergency care following a chemical injury to the eye includes irrigating the eye immediately with water, sterile normal saline, or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is checked. Antibiotics and eye patching may be prescribed, but these are not the initial actions. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? Administering medications that will dilate the pupil Rationale: Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient's eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists prescribe a medication such as 2% pilocarpine to constrict the pupil before surgery. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching? "Sutures are removed in 2 weeks." Rationale: Depending on the type of procedure performed, the client is told that sutures are usually left in place for as long as 6 months. After the sutures are removed and complete healing has occurred, prescription glasses or contact lenses will be prescribed. Options 1, 3, and 4 are correct discharge instructions for the client following keratoplasty. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? Notify the registered nurse. Rationale: Postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon. Options 1, 2, and 4 are inaccurate nursing actions if staining or bleeding is present on the dressing following enucleation. The nurse should notify the registered nurse who would then notify the primary health care provider immediately. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? Straight ahead Rationale: When inserting contact lenses for a client, the nurse tells the client to look straight ahead. This applies to both rigid and soft contact lenses. The other options do not allow the correct eye positioning for inserting the lenses. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride? Select all that apply. 1. "I should apply the eye drops directly over my family member's pupil." 3. "I have to contact the prescriber if my family member develops a small pupil." 5. "I need to wipe off the tip of the eye drop bottle with a tissue between administrations." Rationale: Option 1 indicates incorrect understanding: The eye drops should not be given directly over the pupil. Option 3 indicates incorrect understanding: The intended effect of the medication is pupil constriction, and it is not necessary to notify the prescriber. Option 5 indicates incorrect understanding: Wiping off the eye drop bottle with a tissue would easily transmit infection. Option 2 indicates understanding of using the conjunctival sac as the correct administration site. Option 4 indicates correct understanding that the correct number of drops should be applied. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply. 1. Follow a low-sodium, minimal-caffeine diet with plenty of fiber. 4. Be sure to report halos of light or increased eye pain to your primary health care provider. Rationale: Halos of light and increased eye pain are symptoms of increased intraocular pressure, which should be reported immediately. Low sodium and minimal caffeine intake help lower the intraocular pressure. Eating fiber will prevent constipation. Intraocular pressure is increased when the client strains to have a bowel movement. Most eye drops to treat glaucoma constrict rather than dilate the pupil. The client most likely will need to use glaucoma medications for the rest of his or her life. The eye drops should be placed in the conjunctival sac, not directly over the pupil. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially? Apply ice to the affected eye. Rationale: A traumatic injury with a blunt object is treated immediately with the application of ice. The client should receive a thorough eye examination to rule out the presence of other eye injuries, but this is not the initial action. Eye irrigation is not necessarily required for a blunt injury. The supine position will increase the amount of swelling in the eye. While at home, the nurse receives a telephone call from a neighbor who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye? Secure a paper cup over the affected eye. Rationale: If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye as in this case. This object must never be removed except by an ophthalmologist because it may be holding ocular structures in place. Irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The appropriate initial action by the nurse is to protect the affected eye with a covering, such as a paper cup, that will not apply pressure to either the protruding object or to the eye itself. The nurse can then accompany the neighbor to the emergency department. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially? "Did you flush the eye following the injury?" Rationale: Emergency care following a chemical burn to the eye includes irrigating the eye immediately with tap water or sterile normal saline or ocular irrigating solution, if available. Irrigation should continue until ocular pH reaches approximately 7.5 to 8. Although the other options represent appropriate data collecting questions, the initial assessment in this situation should focus on the type of treatment that took place immediately following the injury. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse? Bright red drainage on the dressing Rationale: If the nurse notes bright red drainage on the dressing, it must be reported immediately because this can indicate hemorrhage. Complaints of pain are expected in the postoperative period. A blood pressure of 122/84 mm Hg is near normal range. A respiratory rate of 22 breaths per minute, although slightly elevated, does not warrant immediate notification of the registered nurse. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"? Use a flashlight to coax the insect out of the ear. Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or humming noise. In the emergency department, mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect that is then removed by using ear forceps; it is not appropriate for the individual to irrigate the ear. Suggesting the use of antibiotics is inappropriate. Which actions should be performed when communicating with a client with presbycusis? Select all that apply. 2. Speak slowly and distinctly. 3. Face client when speaking. 5. Use short sentences and phrases. Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Here are some communication techniques. Speak slowly and distinctly. Ensure that the client can see your face clearly. Do not turn away while speaking. Provide adequate lighting directed toward your face. A strong light behind you creates a glare and makes it hard to see your features. Have a writing pad or Magic Slate available. Use it if the client cannot understand you or if you do not understand the client. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet? Hot dogs Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. Although cereal products contain sodium, the amount is not as high as that found in hot dogs. Apple juice and Brussels sprouts are low-sodium foods. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention? Assessment of cranial nerve VII (facial) Rationale: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve the remaining hearing and the function of the facial nerve. Cranial nerve VII is the facial nerve. Assessment of the remaining cranial nerves is not specific to this type of surgery. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce? Take acetaminophen if any discomfort occurs. Rationale: The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day, and an eye shield is worn at night. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body that was operated on because this will cause edema and increased intraocular pressure. The client is not to lift more than 5 pounds. A client has been diagnosed with macular degeneration. The nurse should expect to expect which signs and symptoms noted with macular degeneration? Select all that apply. 1. Blurred vision 4. Inability to see the vividness of colors 5. Objects that appear to be the wrong size Rationale: Macular degeneration is bilateral and progressive. Early symptoms may be an inability to see the vividness of colors or to see details. Blurred vision, presence of scotomas, or distortion of vision gradually occurs. Objects may appear to be the wrong size or shape, or straight lines may appear crooked or wavy. As central vision deteriorates, there may be a large dark spot or empty place over the center of what is viewed. The remaining options are signs of cataracts. Which diagnostic test would verify the diagnosis of macular degeneration? Amsler grid test Rationale: In the Amsler grid test, a client with macular degeneration will see distorted or blurred lines. The tonometer measures intraocular pressure, which will be elevated in glaucoma. The Snellen chart determines visual acuity and is expressed in a ratio. Normal vision is considered to be 20/20. The Ishihara chart book determines color-blindness. In addition, genetic tests are available to determine the risk for macular degeneration. The primary health care provider will perform a caloric test. Which is the priority order of the actions to perform this test? Arrange the actions in the order that they should be performed. All options must be used. 1. Explain the purpose and procedure to the client 2. Note if the client has had central nervous system depressants, alcohol, or barbiturates 3. Check for the presence of nystagmus, postural deviation (Romberg sign), and past-pointing 4. Examine and clean the ear canal. 5. Place emesis basin under ear to be tested then irrigate the suspected ear with hot or cold water 6. rrigate until the client complains of nausea and dizziness or nystagmus is observed Rationale: Explain the purpose and the procedure to the client and that the caloric test will irrigate the ears to assess for dizziness. Note if the client has had central nervous system depressants, alcohol, or barbiturates because they alter test response. Before the test, the client is examined for the presence of nystagmus, postural deviation (Romberg sign), and past-pointing. This examination provides the baseline values for comparison during the test. The ear canal should be examined and cleaned before testing. The ear on the suspected side is irrigated first because the client's response may be minimal. After an emesis basin is placed under the ear, the hot or cold irrigation solution is directed into the external auditory canal until the client complains of nausea and dizziness, or nystagmus is observed. This usually occurs in 20 to 30 seconds. If after 3 minutes no symptoms occur, the irrigation is stopped. The client is tested again for nystagmus, past- pointing, and Romberg sign. After approximately 5 minutes, the procedure is repeated on the other side. A perforated eardrum is suspected in a client who was hit in the ear with a basketball. A tympanoplasty was performed. The nurse is giving the client discharge instructions. Which client statement indicates a need for further teaching? "I will drink from the plastic bottle mouth since I can't use drinking straws." Rationale: Some discharge instructions concerning tympanoplasty include sneezing, coughing, and nose blowing because all of these actions could disturb the operative site. If necessary, blow the nose gently one side at a time. Cough or sneeze with the mouth open. Continue this for 1 week after surgery. Do not drink through a straw for 2 to 3 weeks. Avoid drinking directly from the mouth of a plastic bottle because negative pressure occurs if the bottle opening is sealed. Keep the ear dry for 4 to 6 weeks after surgery by placing a cotton ball covered with petroleum jelly (such as Vaseline) in the ear canal. Do not fly until the surgeon allows it The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to determine what? The ability to demonstrate effective peripheral vision Rationale: The confrontation test is a gross measurement of peripheral vision. In the Amsler grid test, a client with macular degeneration will see distorted or blurred lines. The tonometer measures intraocular pressure, which will be elevated in glaucoma. The Snellen chart determines visual acuity and is expressed in a ratio; 20/20 is considered to be normal. The nurse in a health care clinic is assisting in testing the client for accommodation. Arrange the actions and observations in the order that they should occur. All options must be used. 1. Focus on distant object. 2. Pupils dilate. 3. Focus on close object. 4. Pupils constrict. 5. Document findings. Rationale: The nurse tests for accommodation by asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object such as a finger held about 3 inches from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes. A client has bilateral aphakia. When reinforcing teaching instructions regarding the prescribed eyeglasses, the nurse determines the need for further teaching when the client makes which statement? "My peripheral vision will not be distorted." Rationale: Aphakia is the absence of the eye's lens and is corrected by prescriptive glasses, contact lenses, or an intraocular lens implanted surgically. Although glasses can be used for this disorder, they have several disadvantages. With the use of glasses, only central vision is corrected and peripheral vision is distorted. There is approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted. It is difficult for the client to judge distances such as when driving a car. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? "No eating or drinking for at least 18 hours before the surgery." Rationale: The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing per mouth (NPO) for 18 hours before surgery. Options 2, 3, and 4 are correct instructions regarding care related to cataract surgery. The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client? On the left side with the head of the bed elevated Rationale: Following cataract extraction, the client should be positioned comfortably on the nonoperative side with the head of the bed elevated. The client should not be placed on the operative side because this position will promote swelling and edema in the operative area. A supine position will also promote edema and swelling. A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action? Obtain a history regarding the cause of the injury. Rationale: In the event of an eye injury, the initial nursing action is to determine the cause of the injury and when the injury occurred. Treatment depends on the cause of the injury. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate? Cover the eye with cold, sterile saline gauze. Rationale: The appropriate nursing action following blunt trauma injury to the eye is to cover the eye with sterile gauze saturated with cold, sterile saline. The nurse should avoid applying pressure and should allow the eye to bleed. The eye should not be irrigated without a primary health care provider's prescription. Skull series are prescribed by the primary health care provider. A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action? Test the eye pH with litmus paper. Rationale: If a client sustained a chemical injury to the eye, the client's head should be tilted to the side of the affected eye and irrigated thoroughly. The pH of the eye should be tested with litmus paper before, during, and after irrigation. The primary health care provider should be notified. A pressure dressing is not placed on the eye in this type of injury. Covering the eye with sterile saline solution is not an appropriate action and would delay necessary and immediate treatment. A medical history would be obtained once initial treatment is initiated. The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question? Administer medication to dilate the affected pupil. Rationale: In the preoperative period, the primary health care provider may prescribe medications such as 2% pilocarpine to constrict the pupil before a keratoplasty. The nurse would question a prescription that indicated dilation of the pupil. Preoperative preparation may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic eye medication, and cutting the eyelashes. The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching? "In 1 week, I'll return to have the sutures removed." Rationale: Following keratoplasty, sutures are usually left in place for as long as 6 months. The client is instructed not to lie on the operative side and should avoid sudden head movement. The client is instructed to instill antibiotic medication because infection is a critical complication of this procedure. An eye shield should be worn during sleep for about 2 months postoperatively. The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action? Contact the registered nurse. Rationale: Following enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the surgeon needs to be notified immediately. The nurse would contact the registered nurse who will assess and then immediately contact the surgeon. Options 2, 3, and 4 are not appropriate initial nursing actions. A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures? "I should apply warm packs to my eye." Rationale: A chalazion is a cyst that results from blockage of sebaceous material in a meibomian gland. Application of warm compresses over the affected eyelid three or four times per day is a common treatment in the early stages. The condition is not contagious, and it is not necessary for the client to use separate washcloths and towels. The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions? "I should apply antibiotic ointment as prescribed." Rationale: Therapeutic management of a hordeolum includes application of warm compresses for 15 minutes 4 times daily and the installation of antibiotic ointment to combat infectious organisms. The client is told not to press on or squeeze the sty because such pressure could force infectious material into the venous system of the eyelids and face, which can transmit infection to the brain. The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result? Normal Rationale: The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Options 2, 3, and 4 are incorrect. The nurse is assisting the primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result? Normal Rationale: The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. Options 2, 3, and 4 are incorrect. The nurse is assisting a primary health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result? Positive Rationale: The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. No nystagmus indicates dysfunction of cranial nerve VIII. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test? An otoscope Rationale: A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine whether the ear canals contain cerumen, which must be removed before the test. An ophthalmoscope, tongue blade, and emesis basin are not essential items. A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply. 2. A client who has a profound hearing loss in both ears 4. A client who has received no benefit from conventional hearing aids Rationale: Adults who were born deaf or became deaf before learning to speak are usually not candidates for this type of surgery. Criteria for a cochlear implant are bilateral profound hearing loss, the client who communicates primarily by speech, the client who receives no benefit from conventional hearing aids, evidence of strong family and social support, and the client who has realistic expectations of the outcome of the implant. Cause of deafness such as infection is not a consideration for the procedure. The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply. 2. Speaking slowly and clearly 3. Standing directly in front of the client while speaking 5. Turning down the volume on the radio or TV when talking Rationale: When communicating with a hearing-impaired client, the nurse stands directly in front of the client or angles the mouth so that sound reaches the client's better ear. The nurse speaks slowly and clearly in a normal tone of voice. Competing noises such as a radio and TV should be minimized. The nurse can use gestures only as long as they are appropriate and used in moderation. All of these approaches will enhance the communication process and minimize the client's self-consciousness about hearing loss. The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity? Watch television. Rationale: The client is taught to avoid doing activities that raise intraocular pressure because it could cause complications in the postoperative period. For this reason, the client should avoid bending over, lifting heavy objects, straining, sneezing, and making sudden movements. The client is also taught to avoid activities that cause rapid eye movements because these would be irritating in the presence of postoperative inflammation. For this reason, the client is told not to read. Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure. The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching? "I need to call the doctor if I develop any fever." Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foul-smelling drainage, or redness at the surgical site. The client should protect the eye by wearing sunglasses during the day and an eye shield at night. The client should lie on the back or the nonoperative side unless otherwise instructed by the surgeon. client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? Detached retina Rationale: Clients with a history of cataract surgery, myopia, trauma, or a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision. Clients with these risk factors should be taught the signs and symptoms of a detached retina and should report them promptly. Options 1, 2, and 4 are not associated risks. A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. The nurse has given the client instructions on how to administer the eye drops. Which client statement indicates a need for further teaching? "I will drop the eye drop in the middle of my eye." Rationale: This is the procedure for administering eye drops. Remove the cap and place it on the table on its side or upside down. With the client sitting or reclining, ask the client to look up at the ceiling and tilt the head slightly toward the eye receiving the drop. With a tissue beneath the fingers, retract the lower lid downward, exposing the conjunctival sac. Stabilize the eye drop container above the eye and drop the designated number of drops directly into the conjunctival sac. Do not place drops on the cornea. Block the entrance to the lacrimal gland by placing a finger over it. Carefully replace the cap on the container without contaminating the dropper tip. Ask the client to close the eyelids gently and move the eyes from side to side under the lids to distribute the medication. The nurse interprets that a client diagnosed with glaucoma needs additional information about the expected effects of this condition when the client makes which statement? "Taking my daily walk right around dusk each evening has proven to be so enjoyable." Rationale: The client with impaired vision because of glaucoma should take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and avoiding walking or driving at dusk or dawn. The client also should understand the need for ongoing monitoring of vision status. The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? Select all that apply. 1. Pulling the auricle of the right ear upward 2. Pulling the auricle of the right ear backward 3. Warming the solution to room temperature 4. Placing the client in a left side-lying position Rationale: The dropper is not allowed to touch any object or any part of the client's skin. The solution is warmed before use. The client is placed on the side with the affected ear directed upward. The nurse pulls the auricle upward and backward and instills the medication by holding the dropper about 1 cm above the ear canal. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder? Agrees to use a prescribed hearing aid especially when home alone Rationale: Presbycusis is a progressive sensorineural hearing loss that occurs as part of the aging process. Some clients do not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid. Clients show adequate adaptation by obtaining and regularly using a hearing aid. Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client? "The edema is normal and should subside within 3 days." Rationale: After surgery to remove cataracts, it is normal for edema of the conjunctiva, sclera, and eyelids to be present. This is due to the trauma of surgery and should resolve in 3 or fewer days following surgery. Options 2, 3, and 4 are incorrect. A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client? Explain that vision will improve with adjustment to aphakic lenses. Rationale: The client who had cataracts removed without intraocular lens implant will have blurry vision. The vision improves with the wearing of aphakic lenses. Depending on the degree of visual impairment preoperatively, this may or may not be an actual worsening of the client's original vision. Options 2, 3, and 4 are incorrect. A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activities to prevent barotrauma during takeoff and landing? Select all that apply. 1. Chewing gum 2. Yawning occasionally 3. Swallowing a few times 5. Sucking on a piece of hard candy Rationale: Clients who are susceptible to barotrauma should do any of a variety of mouth movements to equalize pressure in the ear, particularly during takeoff and landing of an aircraft. These include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because it enhances pressure buildup behind the tympanic membrane. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the primary health care provider? Use a shower cap to protect the ears if taking a shower. Rationale: It is important to avoid getting water in the ears following insertion of ear tubes. For this reason, swimming, showering, and hair washing are avoided after surgery for a period of time that is specified by the surgeon. A shower cap or earplug may be used during showering if allowed by the primary health care provider. The client should take medication as advised for postoperative discomfort. An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history? Whether the client has had a recent upper respiratory infection (URI) Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache, fullness in the ear, nausea with possible vomiting, and fever. The client may complain of decreased ability to hear in that ear. The nurse first takes a client history, assessing whether the client had a recent URI. It is unnecessary to question the client about head injury or ringing in the ear. The nurse may ask the client whether anything relieves the pain, but the pain that accompanies ear infection is not usually relieved until antibiotic therapy is started. When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction? To check the battery regularly to ensure that it is working before use Rationale: The client should check the battery of the hearing aid before use. Lubricants or other solvents are not used around or on the devices. It should be cleaned according to the manufacturer's directions, which usually consist of washing with warm soapy water followed by thorough drying. The hearing aid should be removed for showering because it should not get wet between recommended washings. It should also be put away in its case at night for protection against damage. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if which guideline is followed? Taking the medication 1 hour before a triggering event Rationale: To be most effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate, scopolamine, meclizine, promethazine, and prochlorperazine. The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation? Difficulty with driving a car at night Rationale: A cataract is characterized by a cloudy lens that results in blurred vision and difficulty driving at night. There is sometimes monocular diplopia, photophobia, and glare. The client does not experience eye pain. The other options are incorrect. A client has been diagnosed with open-angle glaucoma. Which signs and symptoms are found in open-angle glaucoma? Select all that apply. 1. Blurred or hazy vision 2. Colored rings around lights 3. Tonometry reading 30 mm Hg Rationale: The National Society for the Prevention of Blindness includes these symptoms as danger signals of open-angle glaucoma: blurred or hazy vision that clears up after a while, seeing rainbow- colored rings around lights, and narrowing of vision at the sides of one or both eyes. Normal intraocular pressure is 10 to 21 mm Hg. The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice? Keep an extra battery readily available. Rationale: The client should keep an extra hearing aid battery available. The hearing aid should be shut off when not in use so that the battery is not drained. If the hearing aid makes a whistling noise, the client should adjust its position in the ear. After cleaning the ear mold, the client should dry it thoroughly before reattaching it to the hearing aid. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the primary health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply. 1. Lidocaine 2. Mineral oil 3. Ether solution Rationale: Water should not be used in the ear canal if an insect is trapped in it. The water will cause the insect to swell making removal more difficult. The other solutions are acceptable because they will either kill or stupefy the insect. After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention? Prescription of corrective lenses Rationale: Errors of refraction in vision include astigmatism, presbyopia, myopia, and hyperopia. Corrective lenses, or eyeglasses, are the most common method used to correct errors of refraction. Eye drops would be used for several eye conditions, most commonly glaucoma. The client may or may not need rigid contact lenses, and this is not the most common treatment. A keratoplasty is a surgical procedure for cataracts. The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply. 2. "I can lie on my right side." 5. "I will wear my eye shield only during the daytime." Rationale: The client should not lie on the operative side in order to reduce strain on the surgical eye. The eye shield should be worn at night. The statements in options 1, 3, and 4 are correct and indicate the client properly understands postoperative restrictions. The nurse is reinforcing discharge instructions to a client following right eye corneal transplantation surgery. The nurse determines that the client understands the instructions if the client makes which statement? "I will lie on my back or left side." Rationale: Following corneal transplant surgery the client is instructed to lie only on his or her back and nonoperative side. A pressure dressing and eye shield are applied in the surgical suite after the procedure and should be removed only by the provider the next day. The shield is then worn at night and when around small children or pets for at least a month. It does not need to be worn all the time. Graft rejection is a possibility and is heralded by inflammation beginning near the graft edges. This finding must be reported promptly. The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included? Myringotomy Rationale: Myringotomy is a surgical procedure that allows fluid to drain from the middle ear. Bed rest is not required, but activity may be restricted. The mastoid bone is removed or partially removed for chronic otitis media. Diphenhydramine is an antiemetic used to treat nausea and vomiting. The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information? Safety Rationale: Attacks of Ménière's disease come on suddenly and can be dangerous. The client is at risk for falls and requires information about how to prevent injury when symptoms begin. This information is highest in priority to maintain the client's well-being. The information listed in the other options is also needed but has lesser priority than preventing falls or injury. The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply. 1. Tonometry 3. Visual field check Rationale: Tonometry is an effective screening test for early detection of glaucoma. Glaucoma can cause a loss of the visual field so that also must be checked. The Snellen chart is used to check visual acuity. Electroretinography determines the electrical potential of the retina. Fluorescein angiography determines abnormal blood vessels or blood flow of the retina. The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care? Place an eye patch over the affected eye. Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the primary health care provider. Visitors do not need to be restricted. The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client? Increase fluids and take a stool softener daily. Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, avoid air travel, and avoid coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks. The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which documented findings should the nurse expect to note if this disorder is present? Select all that apply. 1. Headache 3. Elevated white blood cell count 5. Swelling behind the ear on affected ear Rationale: Signs and symptoms of mastoiditis include mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood cell (WBC) count. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The client has a history of heart disease. The nursing instructor asks the student about group of medications used to treat glaucoma that would be contraindicated? Alpha2-adrenergic agonist Rationale: All of these medication groups can be prescribed to treat glaucoma; however, alpha2-adrenergic agonist medications are contraindicated in heart disease. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used. 1. Warm the prescribed solution to body temperature (95° F to 105° F). 2. Have the client sit up holding an emesis basin under the ear to be irrigated with a drape under the basin. 3. Straighten the external canal of an adult by pulling the auricle up and back. 4. Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. 5. Direct the solution toward the top of the canal in a steady stream, not toward the eardrum Rationale: The nurse would perform an ear irrigation in the following order: (1) Warm the prescribed solution to body temperature (95° F to 105° F). (2) Have the client sit up and hold an emesis basin under the ear to be irrigated. Drape the shoulder under the basin. (3) Straighten the external canal of an adult by pulling the auricle up and back. For a child, pull the auricle down and back. (4) Select an irrigating syringe or bulb syringe with a tip that is smaller than the canal. (5) Direct the solution toward the top of the canal in a steady stream not toward the eardrum. The procedure can be repeated if needed. A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma? "I need to take my eye drops for the rest of my life." Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. Clients need to be instructed that medications will need to be taken for the rest of their lives. Limiting fluids and reducing salt will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan. The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which actions are performed by the UAP during communication with the client? Select all that apply. 1. The UAP speaks in a very loud voice. 3. The UAP speaks while cleaning the room. 4. The UAP speaks directly into the impaired ear. Rationale: When communicating with a hearing-impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. Speak slowly and distinctly. Use short sentences or phrases. Ensure that the client can see your face clearly. Do not turn away while speaking. client has been diagnosed with a hearing loss caused by age-related changes in the ear. The nurse reinforces information about obtaining and learning to use a hearing aid. Which statement by the client indicates understating of the information? "I should obtain a hearing aid as soon as possible." Rationale: The sooner a client with a hearing loss obtains and learns to use a hearing aid, the greater the hearing improvement. The brain is better able to integrate the hearing aid transmissions when hearing has not been impaired for a very long time. The client should be told that there is an adjustment curve with new hearing aid use, and it often takes several trips back to the hearing aid center for minor adjustments to the instrument to be made. It also takes practice in using the aid to achieve better hearing. The nurse is reviewing the medical record of a client diagnosed with conjunctivitis. Which signs and symptoms should the nurse expect to be noted? Select all that apply. 1. Itching 3. Redness 5. Sensation of foreign object Rationale: Conjunctivitis is an infection of the conjunctiva of the eye. Signs and symptoms include pain or discomfort, increased tearing, itching, redness, and sometimes a sensation of a foreign object in the eye. Which are age-related changes to the eyes? Select all that apply. 1. Presbyopia 2. Arcus senilis 3. Yellow-tinged sclera 6. Decreased ability to see in dim light Rationale: Some age-related changes include arcus senilis, an opaque ring outlining the cornea that sometimes results from the deposition of fatty globules. The cornea flattens and develops an irregular curvature after age 65 years, causing astigmatism or making an existing astigmatism worse; vision becomes blurred. The sclera develops a yellowish tinge from fatty deposits; thinning of the sclera may cause a bluish tinge. The ciliary muscle has less ability to allow the eye to accommodate, a process responsible for the gradual extension of distance from the eyes at which an item to be read is held (presbyopia). This change usually begins around age 40 years. Pupil size becomes smaller, reducing the ability to see in dim light. Color discrimination decreases and may cause problems. The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation? The client has normal ocular movements. Rationale: The six cardinal fields of gaze track the client's ocular movements horizontally and diagonally to the left and right. These are the responsibility of the coordinated effort of cranial nerves III, IV, and VI. Peripheral and central vision are assessed during testing of visual acuity. The corneal reflex, or blink reflex, occurs with proper function of cranial nerve V (trigeminal nerve). The nurse is giving the client discharge instructions concerning glaucoma. Which client statement indicates a need for further teaching? "I will only take the eye drops until my vision improves." Rationale: Measures to prevent an increase in intraocular pressure (IOP) include a low-sodium (Furstenberg) diet, little caffeine intake, preventing constipation and Valsalva maneuver, and decreasing stress. Glaucoma medication must be taken regularly for life. The client should avoid night driving if possible. A client has been admitted to the telemetry unit with a diagnosis of bradycardia. The nurse is reviewing the client's prescriptions with the registered nurse. The client has a history of open- angle glaucoma. Which prescription should the nurse suggest should be questioned? Atropine intravenously Rationale: Measures to prevent an increase in intraocular pressure (IOP) include a low-sodium diet, little caffeine intake, and preventing constipation and Valsalva maneuver. Glaucoma medication must be taken regularly for life. Atropine is contraindicated for a client with open-angle glaucoma. Docusate sodium is a stool softener. The nurse is giving home care instructions to a client with conjunctivitis. Which client statement indicates a need for further teaching? "I will use a sterile gauze to rub any matter from my eyes." Rationale: Home care for conjunctivitis is directed to prevent spread of infection. Antibiotic eye drops or ointment will be prescribed. Good hand washing and avoiding sharing washcloths help prevent spread of infection. The client can use warm or cool compresses to the eyes for discomfort. The client should avoid rubbing the eyes. After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom? Eye pain Rationale: Common symptoms of acute angle-closure glaucoma are blurred vision, severe pain, and vision loss. Color blindness and difficulty seeing at night are unrelated findings. Yellow-green vision may sometimes accompany digoxin toxicity. A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube? Performing the Valsalva maneuver Rationale: Using the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this. The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull? Temporal Rationale: The ear is housed in the temporal bone of the skull. It is not attached to the other bones listed in options 1, 2, or 4. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 6. Educate regarding symptoms of retinal detachment. Rationale: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a postsurgery risk. Coughing is not encouraged because this can increase intraocular pressure and harm the client. A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl eye drops. Which action by the nurse is most appropriate? Withhold the dose and notify the registered nurse. Rationale: Carteolol HCl is a beta-blocking agent that can constrict bronchial airways and cause narrowing if absorbed systemically. This can lead to bronchospasms. The nurse should notify the registered nurse because the client has pulmonary disease, and the condition may worsen with administration of a beta blocker. The medication would not be administered. The medication is not shaken vigorously. There is no reason to obtain a sample of eye drainage. The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action? Wrap a plastic bag filled with ice with a pillowcase and place it on the eye. Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle or a heating pad. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes, and after a short time, it may be reapplied. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack. The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client? Using many exaggerated hand gestures while talking Rationale: When communicating with a hearing-impaired client, the nurse should stand directly in front of the client or in such a way that sound reaches the client's better ear. The nurse should speak slowly and clearly in a normal tone of voice. Competing noises such as radio and TV should be minimized. The nurse can use gestures as long as they are appropriate and used in moderation. The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract? Difficulty with driving at night and blurred vision Rationale: A cataract is characterized by a cloudy lens that leads to blurred vision and difficulty driving at night. Sometimes the client with a cataract experiences monocular diplopia, photophobia, and glare. The client does not experience eye pain. The other options are incorrect. The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction? "The hearing aid should not be worn if an ear infection is present." Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent noisy feedback. The hearing aid should be turned off when not in use, and extra batteries should be kept on hand. The client should wash the ear mold frequently with mild soap and water, using a pipe cleaner to cleanse the cannula. The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which action? Retract the upper eyelid and ask the client to look down. Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts that direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other options are incorrect. A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to reinforce which information? The need for lifelong medication therapy Rationale: The client with glaucoma experiences increased intraocular pressure. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client must be instructed that lifelong medication therapy is needed to maintain intraocular pressure within the normal limits of 10 to 20 mm Hg. The other options are not necessary in this condition. A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury? Bed rest with the head in semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as a penetrating injury, or indirectly from a blow to the forehead. The client is treated with bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Therefore, options 1, 2, and 3 are incorrect. A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? Irrigate the eye with sterile saline. Rationale: Surface foreign bodies often are removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this risks causing further injury to the eye. Placing an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time and might not be feasible because the client most likely has excessive blinking and tearing as well. A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care should encourage the client to limit or refrain from which usual activity on a repeated basis? Picking objects up off the floor Rationale: The client with glaucoma experiences increased intraocular pressure. The client should avoid activities that cause straining or repeated bending below the waist, which could increase intraocular pressure. Activities that are done at waist level or higher are not contraindicated because they would not adversely affect intraocular pressure. The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. What is the order of structures conducting sound waves from the middle ear to the inner ear? Arrange the structures in the order that they should occur. All options must be used. 1. Tympanic membrane 2. Malleus, incus, stapes 3. Oval window 4. Cochlea 5. Organ of Corti Rationale: The tympanic membrane vibrates when sound waves hit it. The sound vibrations are conducted to the malleus. The bones of the middle ear transmit the sound vibrations to the inner ear. The malleus transmits them to the incus, and the incus transmits sound vibrations to the stapes. The stapes transmits the sound vibrations to the oval window, which transfers the motion to the fluid in the inner ear. Fluid motion in the inner ear stimulates the sound receptors in the cochlea and the organ of Corti. Which medications cause ototoxicity? Select all that apply. 1. Ibuprofen 3. Furosemide 4. Vancomycin Rationale: Ototoxicity is caused by medications or chemicals that damage the inner ear or the vestibulocochlear nerve. There are more than 200 medications that cause toxicity. The vestibulocochlear nerve sends balance and hearing information from the inner ear to the brain. Ototoxicity may result in temporary or permanent disturbances of hearing, balance, or both. This is especially true if a very high dose of the medication is given or if it is given incorrectly. Ototoxic medications include furosemide, ibuprofen, and vancomycin. An adult client has increased fluid in the middle ear that is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition? Nausea and vomiting Rationale: Vertigo commonly affects the gastrointestinal system by causing nausea and vomiting. Vertigo can be the result of fluid in the middle ear or may be due to a disorder of the inner ear. This disorder would not cause headache, flushing, tinnitus, or difficulty in swallowing. Fluid in the ear may or may not be uncomfortable for the client, depending on individual circumstances. The client may have a slight, temporary difficulty in hearing if there is fluid in the middle ear. The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner? In a normal tone while facing the client Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone and not shout. The nurse should speak clearly and directly to the client while facing the client. If the client does not seem to understand what is said, different words should be used to express the message. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the impaired ear. The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect? Acetaminophen Rationale: Acetaminophen is toxic to the liver (hepatotoxic) in large doses. It does not result in ototoxicity. The medications listed in options 1, 3, and 4 carry ototoxicity as a risk of therapy. A client who frequently experiences hearing loss due to built-up cerumen in the ears asks the nurse about ways to deal with the problem including irrigating the ears. Which information is correct for the nurse to include in the teaching plan? Select all that apply. 2. Irrigate the ear canal with lukewarm tap water around 98° F. 4. The ear irrigation should be stopped if the client becomes dizzy or nauseous. 6. Instill drops of mineral oil and hydrogen peroxide for several days to soften dried cerumen before irrigation. Rationale: Impacted cerumen is a frequent cause of hearing deficit in adults. In older adults especially, cerumen becomes dry and thick causing conductive hearing loss. Impacted cerumen can be removed by careful irrigation of the ear canal and can be taught to clients. Warm water (98° F to 99° F) is gently directed at the top of the canal above or below the impacted cerumen. Instillation of 3 drops each of mineral oil and hydrogen peroxide twice daily for several days before the irrigation will soften the cerumen. Using too cool or warm water may cause the client to experience a vestibular reaction causing nausea and dizziness. Clients should not use any foreign object to place inside the canal. Daily ear hygiene should consist of washing the external ear with a soapy wet washcloth. Avoiding foods high in sodium is recommended to avoid vertigo attacks caused by Ménière's disease but is not helpful in decreasing ear cerumen. Directing the flow of water straight into the ear during an irrigation will hit the tympanic membrane (eardrum) and cause pain and possible perforation. The nurse administers meclizine hydrochloride to a client diagnosed with an attack of Ménière's disease. Which observations demonstrate to the nurse that the medication is effective? Select all that apply. 2. Decrease in nausea 3. Decrease in vertigo Rationale: Ménière's disease is a condition in which the client is incapacitated with episodes of tinnitus (ringing in the ears), hearing loss in one ear, and vertigo (severe whirling sensation). These symptoms are due to excessive endolymph present in the inner ear, disturbing the client's ability to hear and the sense of balance. Meclizine hydrochloride, a medication that has antihistamine properties, is prescribed to control vertigo and the nausea and vomiting that accompany the vertigo. Seizures, stiff neck, and ear pain are not associated with Ménière's disease. Drowsiness is an adverse effect of meclizine hydrochloride. The nurse is reinforcing discharge instructions to a client who just underwent a myringotomy with placement of a polyethylene tube in the left ear. Which statement by the client indicates a need for further teaching? Select all that apply. 1. "I may wash my hair tomorrow." 2. "I expect to have improved hearing." 3. "I expect to have fewer ear infections." 4. "I will irrigate the ear with gentle pressure." 5. "I can expect to feel pressure inside the ear." Rationale: A myringotomy is the procedure in which a surgical opening is made in the tympanic membrane (eardrum). A polyethylene tube is placed in the opening to keep it open for a period of time to let fluid drain from the middle ear. This procedure relieves pressure and pain from the fluid buildup associated with frequent episodes of otitis media. This release of fluid improves sound conduction and hearing. The client needs to know that the ear should be kept dry to promote healing. The client should refrain from hair washing for several days and should not irrigate the ear. With the tube maintaining the opening in the tympanic membrane, the client should not feel pressure in the ear. Avoiding persons with colds decreases the likelihood the client will be exposed to contagious viruses. A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? Detached retina The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. 1. Have the client void before surgery. 4. Determine that the client has signed the informed consent for the surgical procedure. Rationale: The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client. The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns? Ask the client to discuss information known about the planned surgery. Rationale: The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 4. Wonders if the surgery could cause incontinence 6. History of deep venous thrombosis in right leg 10 years earlier Rationale: The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery is communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy to avoid an allergic reaction perioperatively. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that needs to be reported specifically. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions should the nurse take? Select all that apply. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU). Rationale: In a clinical situation, the nurse must evaluate the vital signs of each postoperative client individually. If complications such as hemorrhage or shock are developing, early intervention is extremely important. Determining how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs. Accessing the medical record to determine the most recent analgesic administration is pertinent because hypotension is a frequent side/adverse effect of analgesics, especially opioids. Reviewing the client's record gives the nurse data on the client's vital signs during and after surgery in the PACU, and the nurse can evaluate whether there has been a change. Giving the client oral fluids is an intervention if the client has a fluid volume deficit and this has not been established. Oral fluids would not correct the problem as quickly as administering IV fluids would. Collecting data about the client voiding is not directly related to the vital signs. Encouraging leg exercises is a correct postoperative intervention, but is not appropriate for evaluating the vital signs. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? Assess patency of the airway. Rationale: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains. The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? A urinary output of 20 mL/hour Rationale: Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? Pneumonia Rationale: Pneumonia is a postoperative condition caused by inflammation and infection in the lungs. Frequently it results from shallow breathing that leads to atelectasis (the alveoli partially collapse and eventually become fluid-filled). This fluid is good medium for bacteria. Pneumonia usually occurs 3 to 7 days postoperatively. Signs and symptoms include fever, productive cough, painful breathing, and an increased respiratory effort and rate. Fine crackles may be audible over the lung area involved. Treatment includes coughing up the purulent sputum, deep breathing, antibiotics, and adequate hydration. Hypoxia is inadequate concentration of oxygen in the blood and usually occurs as an acute process, such as respiratory depression as a result of anesthesia or analgesia, or the pulmonary oxygen saturation is relatively below normal, less than 92%. Atelectasis occurs 1 to 2 days postoperatively, and auscultation reveals diminished breath sound and/or crackles that clear with coughing. Fluid overload is excessive blood volume with too much fluid in the circulation. It causes coarse crackles and severe dyspnea. The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. Rationale: A drain is a tube that is placed to drain out fluid and blood near the surgical site and could lead to infection. The tube is connected to a bulb, which is compressed to create a vacuum and pull out the fluid. The nurse should check for patency and that fluid is being pulled out. The bulb should be, and look, decompressed in order to create the vacuum. The drainage usually is dark red as a result of blood content, but may be pale yellow with serous fluid. Aseptic technique must be used when emptying the drainage container to avoid contamination of the wound. The bulb of the drain should be emptied when it is half full and at least every 8 to 12 hours. The amount of drainage is documented in the client medical record under intake and output. Curling or folding the drain prevents the flow of the drainage. The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 2. The presence of purulent drainage 6. Tender firmness palpable around the incision Rationale: A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort. The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Rationale: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The registered nurse (RN) and primary health care provider (PHCP) need to be notified. The client should assume a low-Fowler's position with knees bent to avoid further stress on the incision. Obesity is a risk factor for dehiscence, but now is not the appropriate time for this teaching. The nurse should not explore the incision because this may actually cause evisceration, a more serious complication. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position? 4. Supine, with the residual limb supported with pillows Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the surgeon's prescription(s) regarding positioning following amputation. The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside? Suction equipment Rationale: In a postoperative client, a concern related to initiating a diet is aspiration. Initiating postoperative oral fluids may lead to distention and vomiting. Suction equipment must be available. A blood pressure cuff may be necessary but is not the priority from the options provided. A code cart is unnecessary. A straw may help the client sip fluids but is not necessary. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate? "You are concerned that you don't feel any better after surgery?" Rationale: Paraphrasing is restating the client's message in the nurse's own words. Paraphrasing may be in the form of a question. Option 4 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding. Options 1, 2, and 3 are inappropriate communication techniques. Option 1 belittles the client's concerns. Options 2 and 3 offer false reassurance by the nurse. The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Select all that apply. 1. Increasing restlessness 3. Unrelieved pain despite receiving analgesics Rationale: Increasing restlessness and unrelieved pain despite receiving analgesics are signs that require continuous and close monitoring because they could be potential indications of a complication, such as hemorrhage or shock. A temperature of 98.9° F is normal. Faint bowel sounds heard in all four quadrants is a normal occurrence. A blood pressure of 114/66 mm Hg with a pulse of 96 beats per minute is a relatively normal sign. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out? To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site Rationale: The time-out occurs in the perioperative area after the client has been prepped and draped. The entire team must verbally verify its agreement regarding the client's name, the procedure to be performed, and the surgical site (e.g., which leg, which side). The client has already been explained the surgery and associated risks and had an opportunity to decide to cancel the procedure when taken to surgery. This is a stressful time for the client and discharge instructions will probably not be retained. The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong- site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure Rationale: The surgeon is responsible for verifying the operative site, and he or she must mark the operative site before the client is brought into the operating suite. The client will be asked to verify the site that requires surgery. The client may refuse to have the site marked and is asked about marking the site. Although the nurse may also verify the site, this procedure is a primary responsibility of the primary health care provider. Verification of the site should be done both before and during the time-out period. The verification of the surgical site is not done at the completion of the procedure. A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1. Notify the registered nurse immediately. 2. Document the client's complaint with the exact times. 4.Prepare the client for wound closure by notifying surgery department. 6.Instruct the client to remain quiet and reassure the situation is being taken care of. Rationale: Wound dehiscence is the separation of the wound edges, and wound evisceration is the protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the registered nurse is notified, and he or she then contacts the surgeon immediately. The client is placed in a low-Fowler's position, kept quiet, and instructed not to cough. Protruding organs are covered with a sterile, saline dressing. Ice packs are not applied. The treatment for evisceration is immediate wound closure under local or general anesthesia. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings? The incision line is slightly edematous but shows no active signs of infection. Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, and induration. An elevated temperature and elevated WBC count after 3 to 4 days usually indicate infection. A WBC count of 7500 mm3 (7.5 × 109/L) is within the normal range. Normal WBC is 5000 to 10,000 mm3 (5 to 10 × 109/L). The nurse in the primary health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client? "These sensations lessen over several months and usually are gone after 1 year." Rationale: Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve 1 year after surgery. Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct? "LR is isotonic to plasma and contains electrolytes" Rationale: Lactated Ringer's solution is an isotonic solution. It contains calcium, potassium, sodium, chloride, and lactate in small amounts. Other isotonic solutions include 5% dextrose in water, 0.9% normal saline, and 5% dextrose in 0.225% normal saline. Isotonic solutions are used for fluid replacement in surgical clients. The fluid will remain in the vascular space. The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. 4. Frequent assessment of vital signs 5. Coughing and deep breathing exercises 6. Pain monitoring and medications to relieve pain Rationale: The type of planning and instruction required varies with each individual and type of surgery. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery? Pain Rationale: The client who has had abdominal surgery is most likely to experience pain in the first 24 hours after surgery. The other options identify less important issues during this time frame but could increase in importance later in recovery. Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table? Apply the safety strap 2 inches above the knees. Rationale: The safety strap is applied to prevent the client from falling off the surgery table. The strap should be applied 2 inches above the knees to avoid pressure on the popliteal nerve. Options 1, 3, and 4 are inappropriate and unsafe. Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose? To prevent thrombosis formation in the veins Rationale: Compression devices, whether sequential, pneumatic, or intermittent, are external devices applied to the lower extremities to compress the calves of the legs and return blood to the heart similar to the way walking promotes venous return. These compression devices are used for clients who are in bed, especially during surgery and postoperatively, to prevent the complication of venous thrombotic embolism. This embolism can become a pulmonary embolism and cause death during the postoperative recovery period. Heart function determines arterial circulation. The compression devices are not significant in preventing muscle cramps or maintaining muscle strength. The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter? Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). The pulse oximeter does not replace arterial blood gases, but it is an effective tool to monitor the client for subtle or sudden changes in oxygen saturation. It is not the oxygen liter flow that may be prescribed for a client, the oxygen level from arterial blood gases, or the end tidal carbon dioxide, which is measured on exhalation and is more sensitive to hypoxemia that oxygen saturation. The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching? "I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home." Rationale: The client should be instructed to limit upper arm ROM to the level of the shoulder only. After the axillary drain is removed, the client can begin full ROM exercises to the upper arm as prescribed by the primary health care provider. Elevating the arm above the heart level while sitting or lying down, massaging the area with cocoa butter after the incision is completely healed if prescribed by the primary health care provider, and having pain in the absent breast (phantom pain) are correct measures following a mastectomy. The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which data first? A patent airway Rationale: After transfer from the postanesthesia care unit, the nurse performs an assessment on the client. Airway must be established first. Urine output, surgical dressing, and orientation to the surroundings also may be checked, but these are not the first actions. A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment? Vital signs Rationale: After observing the client has a patent airway, the nurse should check the client's vital signs. The vital signs will provide information regarding airway, breathing, and the circulatory status of the client. In addition, this information provides a baseline for further assessments. The abdominal dressing, IV, and urine output are also components of the assessment, and these assessments would follow the assessment of the vital signs. The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change? Checking the wound site for drainage from the drain Rationale: The wound site needs to be checked for drainage from the drain; the drainage can excoriate the skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced. The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply. 2. Increasing restlessness 3. A pulse rate of 108 beats per minute 4. A blood pressure (BP) of 88/58 mm Hg 5. Increasing pain unrelieved by analgesics Rationale: Shock that occurs after surgery is most often related to hypovolemia secondary to hemorrhage or inadequate fluid replacement. Increasing restlessness noted in a client is a sign that requires continuous and close monitoring because it could indicate shock. The client may have increasing pain from a buildup of blood internally. Vital sign changes that eventually occur include a drop in BP and an increased pulse rate. Absent bowel sounds are normal in the immediate postoperative period following abdominal surgery. The restlessness may progress to other signs of shock quickly. Remember that early treatment improves the outcome. The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action? Apply a sterile dressing soaked with sterile normal saline to the wound. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be placed in semi-Fowler's position to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider needs to be notified immediately. The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all that apply. 4. Instruct the client not to swallow water with oral hygiene on the morning of surgery. 5. Document that any medications the client was instructed to take before surgery are given. Rationale: The preoperative preparation is important to ensure that the surgery gets done with everything ready to ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not swallow any water. Any specific medications that the client was instructed to take on the day of surgery need to be administered and documented. This may include insulin or a blood pressure medication. The nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the preoperative laboratory studies and notify the primary health care provider of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours. A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions? "I cannot drink or eat anything after midnight on the night before surgery." Rationale: Preoperative instructions are important so that the client is readied adequately for surgery and all has been done to achieve a successful outcome. The client must understand the importance of following the timing of being NPO to lower the risk of aspiration associated with the anesthetic. Antiplatelet medications such as aspirin alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be discontinued abruptly. In fact, additional dosages of the corticosteroid may be necessary before stressful situations, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful. he student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action should be appropriate? Notify the registered nurse. Rationale: Sanguineous drainage is bright red and indicates active bleeding. If active bleeding is present, the registered nurse should be notified. Covering the wound and reassessing in 1 hour will delay needed intervention. Leaving a wound open to air can lead to infection, and the blood will not be contained. The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which should be the nurse's actions at this time? Select all that apply. 4. Check the client's overall intake and output record. 5. Gather data about the urinary catheter and check for patency. Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is a decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. The nurse needs to check that the catheter is draining properly and is not kinked besides reviewing the intake and output. Options 1 and 3 are not implemented without a prescription from the primary health care provider. The primary health care provider is called by the registered nurse (RN) once the nurse has gathered all necessary assessment data and has reported the information to the RN, including the overall fluid status and vital signs. The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? Lower the head of the bed slowly until the dizziness is relieved. Rationale: Dizziness or feeling faint is not uncommon when a postoperative client is positioned upright for the first time after surgery. If this occurs, the nurse relieves the feeling by lowering the head of bed slowly until the dizziness subsides. The nurse would then check the pulse and blood pressure. Because the problem is circulatory, not respiratory, options 2 and 3 are not the first actions to take. The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for adverse/side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication? Client complaints of a dry mouth Rationale: Scopolamine is an anticholinergic medication that frequently causes dry mouth. It may also cause decreased sweating, urinary retention, and pupillary dilation. A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply. 2. Increased risk for dehiscence 4. Increased likelihood of surgical site infection Rationale: Chronic use of glucocorticoids, such as prednisone, increases the risk of surgical site infections and the potential for dehiscence. Wound healing may be slow. Glucocorticoids increase the blood glucose. Excessive bleeding is not associated with glucocorticoids. After abdominal surgery, a client experiences an evisceration. Which client statement supports this diagnosis? "It felt like something just slit me wide open." Rationale: Wound evisceration is the total separation of the layers of the wound and extrusion of internal organs or viscera (usually abdominal) through the open wound. This disruption in wound healing may be preceded by excessive coughing, not splinting the surgical site, vomiting, or straining. The client may state, "something gave way," or "I feel as if I just split open." Itching, discomfort with moving, and redness along the incision line are not signs and symptoms directly associated with evisceration. When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position? Lithotomy Rationale: The thoracic cage normally expands in all directions except posteriorly. In a lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced. Sims', supine, and lateral positions will not compromise lung expansion as much as the lithotomy position would. A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply. 1. Observing perineal pad drainage 2. Observing the abdominal dressing 3. Rolling the client to one side to view bedding 4. Monitoring output from the Jackson-Pratt drain Rationale: The nurse should roll the client to one side after checking the perineal pad and abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity, particularly if the client is lying supine. The nurse should also observe the output from the Jackson-Pratt drain. Auscultation of bowel sounds is related to return of peristalsis. Abdominal distention may occur with air in the bowels not necessarily bleeding. Ecchymosis from the surgical bleeding would not be apparent so soon after surgery. The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication? Skin irritation surrounding the wound Rationale: The use of Montgomery ties, also called Montgomery straps, is a means of securing a dressing without removing and reapplying tape on the skin surrounding the incision. The ties consist of a long strip of material, half of which contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin/rubber band combination that you fasten across a dressing and untie at dressing changes. Montgomery ties are often used with wounds requiring frequent dressing changes and prevent irritation to the skin surrounding the incision. The ties do not lower the risk of dehiscence, paralytic ileus, or wound infection. A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply. 4. "What have you been eating and drinking since the surgery?" 5. "Have you been experiencing any urge to move your bowels?" 6. "What kind and how often have you been taking medications for pain?" Rationale: Constipation is marked by difficult or infrequent passage of stools that are hard and dry. Constipation has numerous causative factors, including psychogenic factors, lack of physical activity, inadequate intake of food and fiber, and medication influences. A client recovering from knee surgery may have several factors influencing elimination patterns. The nurse needs to collect data regarding fluid and dietary intake since surgery, whether the client has been responding to the urge to defecate, and whether the pain medication type and frequency is likely to cause constipation. The presurgery bowel frequency and laxative use are not pertinent since the client has not had a bowel movement for 4 days. The intake of meat is unrelated to constipation. Which types of nourishment should the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply. 1. Coffee 2. Ice chips 3. Beef broth 6. Lemon flavored gelatin Rationale: A clear liquid diet includes fluids or frozen fluids that are clear at room temperature. These food sources are easy to digest and less likely to cause vomiting in a postoperative client. The nurse should assess for the return of the gag reflex first before initiating any oral intake. Coffee, ice chips, beef broth, plain tea, and gelatins are included in a clear liquid diet. Dairy products such as milk or yogurt are included in a full liquid diet. The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which actions? Select all that apply. 2. Ask the client whether he has passed any flatus. 4. Document the finding and continue to check for bowel sounds. Rationale: Bowel sounds may be absent for 3 to 4 postoperative days owing to bowel manipulation during surgery. Passing flatus is another way to determine whether peristalsis is occurring postoperatively. The nurse should document the finding and continue to monitor the client. The suction is not increased on the NG tube, and the client should receive nothing by mouth (NPO) until after the onset of bowel sounds. There is no need to immediately notify the registered nurse. The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements should concern the nurse? Select all that apply. 1. "Yes, I take a full-strength aspirin every day." 4. "I have taken my medication for my blood pressure this morning." Rationale: Clients who are scheduled for GI surgery will be instructed by their primary health care provider or surgeon at least 2 weeks before surgery to stop any medications that can cause bleeding tendencies. Abnormal bleeding during surgery can place the client at risk for adverse surgical complications and increase the need for blood transfusions. Medications that are prescribed to lower the blood pressure may cause problems with anesthesia. The nurse should make sure the surgeon is aware that the client has taken an aspirin and the blood pressure medication. Adjustments may be made in the medications administered during surgery. A multiple vitamin taken the day before, stopping medications as prescribed, and taking the prescribed bowel preparation medications are not concerns that the nurse needs to report. The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling? Semi-Fowler's Rationale: The client who has nasal surgery may have packing in place postoperatively to decrease bleeding. The moustache dressing is a folded piece of gauze to catch any drainage that collects from the packing at the nasal cavity. The nurse should place the client in the semi-Fowler's position because elevating a body part will reduce swelling. The prone and supine positions do not decrease swelling because the client is lying flat. Sims' position, which is side-lying, also does not decrease the swelling. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi- Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important? Informing the surgeon of the situation Rationale: The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action. Although options 3 and 4 may be appropriate, the surgeon needs to be informed about the missing sponge. A client's preoperative vital signs are temperature 98.6° F (37° C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first? Compare these values to those recorded previously. Rationale: Preoperative assessment of vital signs provides important baseline data with which to compare following surgery. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. The nurse should review and compare the vital signs to those recorded previously. The vital signs as stated in the question do not need to be reported to the registered nurse immediately. The apical pulse is not above the normal range and an apical radial pulse for a full minute is not required. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement. The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply. 3. Grief 4. Anxiety 5. Altered body image Rationale: A client facing an elective amputation of a lower extremity will experience psychosocial as well as physical challenges during the perioperative period. The client is likely to experience grief because of the loss of the extremity as well as an alteration in body image. The client will also experience anxiety since this will be a new experience and life as an amputee is unknown. Pain is a physical problem influenced by psychosocial factors. There are no data in the question to support a problem of anger. A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply. 1. Tea 3. Ice cream 5. Cream of tomato soup 6. Cream of wheat cereal Rationale: A full liquid diet consists of the foods on a clear liquid diet plus the addition of smooth dairy products, cream soups, and refined cooked cereals. The client's diet would include tea, ice cream, cream of tomato soup, and cream of wheat cereal. Crackers are on a regular diet. Scrambled eggs are included in a pureed diet. The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions should the nurse include in relationship to prescribed dressing change? Select all that apply. 1.Sit up for coughing while splinting the incision. 5.Remove the binder to change the abdominal dressing as prescribed and reapply. Rationale: Binders are large bandages often made of elastic materials that attach together with Velcro and are applied over the abdominal dressing. After abdominal surgery, a binder is used to relieve tension from the suture line and provide support. This maintains the integrity of the incision, helps prevent dehiscence and wound evisceration, and thereby helps prevent infection. Using a binder, however, can hinder chest expansion, promote shallow breathing, and aggravate residual atelectasis and risk of pneumonia from surgery. The client is instructed to sit up to facilitate diaphragmatic excursion and to splint the incision for client comfort and suture line protection while coughing, deep breathing, and using the incentive spirometer. The binder is removed while the client is supine to have the dressing changed and then reapplied. The binder should be worn while the client ambulates. The binder can be removed when the primary health care provider is not present. The binder is applied fairly tight but not so tight as to impair circulation. The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the primary health care provider has prescribed neomycin sulfate orally for the client. Which is the rationale for prescribing this medication? To decrease the bacteria in the bowel Rationale: Intestinal anti-infectives such as neomycin are administered to decrease the bacteria in the bowel. To reduce the risk of contamination at the time of surgery, the surgeon may prescribe that the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel. The nurse is caring for a postoperative client who had a pelvic exenteration. The primary health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks for which information before administering the clear liquids? Select all that apply. 3. Presence of bowel sounds 5. Whether the client has passed flatus Rationale: Pelvic exenteration is a radical surgery for treatment of gynecological cancer involving removal of the uterus, ovaries, fallopian tubes, vagina, bladder, and urethra. Sometimes the descending colon and rectum may also be removed. The client would have a colostomy and ileal conduit created if part of the colon and rectum and bladder are removed. This surgery is done when no metastases have been found outside the pelvis, and the client is agreeable. It is done less often today. The client is kept NPO until peristalsis returns, usually in 4 to 6 days postoperatively. When signs of bowel function return, clear fluids are given. If no distention occurs, the diet is advanced as tolerated. It is most important to monitor for return of peristalsis by the presence of bowel sounds and passing flatus before feeding the client. Before giving the client liquids, the nurse does not need to inspect the incision, assess pain, or monitor the urinary output. These interventions would be done but are not related to beginning the clear liquid diet. A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "Can you share with me what you've been told about your surgery?" Rationale: In assisting clients to deal with anxiety related to medical treatments, it is important that the nurse focus on the client and promote the expression of feelings. An open-ended question will assist the client to express emotions and concerns. Explanations should begin with the information that the client knows. By providing the client with an individualized explanation of care and procedures, the nurse can assist the client in handling fears and providing a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. The nurse should not trivialize the client's expression of anxiety or cut off communication by giving excessive information and focusing on the surgery and not the client. The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client? Select all that apply. 4. Use the incentive spirometer for 5 to 10 breaths every hour while awake. 5. The best results are achieved when sitting at least halfway or fully upright. Rationale: An incentive spirometer is a volume- or flow-oriented device used to encourage deep breathing by giving visual feedback to the client during its use. For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly. The nurse is preparing the client for transfer to the operating room (OR) because of an emergency situation. The nurse should take which actions in the care of the client? Select all that apply. 1. Ensure that the client has voided. 4. Verify the time that the client last ate or drank. 5. Assist the client by contacting family members the client wants notified. Rationale: A client who is going to surgery on an emergent basis needs to be readied efficiently. The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse should determine when the client last ate or drank to assist the anesthesiologist in determining the type of anesthesia for the surgery. The nurse assists the client with notifying persons who are the client's support system. These interventions are documented in the client's medical record. The nurse does not administer all daily medications just before sending a client to the OR. The time of transfer to the OR is not the time to practice breathing exercises. The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first? Recheck the vital signs in 15 minutes. Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. There are no data in the question suggesting that the client is unarousable or requiring a warm blanket. Warm blankets are applied to maintain the client's body temperature or in the case of shivering. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately. The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply. 2. Review vital signs from previous hour. 3. Observe the urinary catheter for patency and flow. 4. Observe the IV site for patency and correct flow rate. 5. Review when the client last received pain medication. Rationale: Postoperative vital signs and urinary output are important parameters to determine how the client is recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a complication. The nurse should review the previous vital signs to determine whether this is a change from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast. Noting when the last pain medication was administered will help the nurse determine whether the vital signs may be affected from the medication since opioids lower blood pressure. The nurse should determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Auscultation of breath sounds is not part of determining the significance of the vital signs and urinary output. A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply. 1. The bulb container is fully compressed. 2. Bright red bloody drainage is present in the bulb container. Rationale: A surgical drain is a device placed during surgery to collect fluid away from the surgical site. The Jackson-Pratt drain is a bulb collection device that is self-suction and is emptied by releasing the suction, removing the drainage, and then again compressing to apply suction. To check patency, the bulb should be compressed and contain drainage that is usually red bloody drainage on the day of surgery. There is no bubbling or tidaling of the fluid with respirations with a Jackson-Pratt drain. The drainage on the surgical dressing should be minimal if the drain is operating properly. When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to take which action in the initial care of the wound? Apply a sterile dressing soaked with normal saline. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider must be notified after this initial dressing has been applied to the wound. The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply. 1. Increasing restlessness 5. Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute Rationale: Hypovolemia is decreased circulating blood volume. In a postoperative client, this often is associated with inadequate fluid replacement or hemorrhage. Increasing restlessness is a sign that requires continuous and close monitoring because it could forecast a complication such as shock. A low and dropping BP with an increased pulse rate could be early compensation for a decrease in circulating blood volume. The WBC count is normal at 5000 to 10,000 mm3 (5 to 10 × 109/L). Hearing hypoactive bowel sounds in all four quadrants is a normal occurrence, as is a capillary refill of 3 seconds in all extremities. The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply. 1. New floaters 3. Increasing redness in the eye Rationale: Following cataract surgery, in which the cloudy lens is removed and a new lens is implanted in the eye, clients are sent home to recover. Clients should contact the surgeon immediately if there is the presence of new floaters (seeing small dots) because this could be a sign of a detached retina. Some redness in the eye may be present but increased redness could indicate bleeding or infection and should also be promptly reported. Clients usually experience improved vision, a sensation of grittiness in the eye, and pain that is controlled with acetaminophen. The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions should be included in the plan of care? Select all that apply. 1. Elevate the right arm on one or two pillows. 5. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm. Rationale: The client, who has undergone a mastectomy (removal of the breast) procedure, is at risk for developing lymphedema due to disruption of the lymph circulation. The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema (accumulation of lymph in soft tissue). Placing a sign stating no venipunctures or BPs in the operative arm will inform all health care workers of the precautions needed to prevent infection or blockage of lymph channels in the arm. Checking the radial pulse in the right arm will not block lymph circulation. The left arm needs no precautions because the lymph circulation is intact on that arm. The client may bend the fingers and not bending them will likely promote edema. The nurse is taking care of a client preoperatively. The client is NPO and an intermediate and short-acting insulin are scheduled for 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take? Call the primary health care provider (PHCP) for clarification. Rationale: The diabetic client who is going to surgery will not have the usual diet and will not require the routine prescribed insulins. The primary health care provider should be notified to prescribe an adjusted insulin dosage for the day of surgery. The nurse must contact the PHCP for clarification of the prescription and should not give the medication because it might lead to hypoglycemia during surgery. The nurse should not withhold the insulin because this might lead to hyperglycemia during surgery and can cause increased risk for infection and impaired wound healing. The nurse may obtain the finger stick glucose reading but this should be reported to the PHCP when seeking clarification. [Show More]

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