- Facial rubor.
- Anthropometric measurements.
- Dry skin.
- Bleeding gums.
Anthropometric measurements are the prime parameters used to evaluate fat and muscle stores in the body. Bleeding gums and dry skin are associated with several systemic problems and can be signs of micronutrient deficiencies as well. Facial rubor is not a parameter used to evaluate the client's nutritional status.
2. Total parenteral nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except
- trace minerals.
- dextrose 10%.
- amino acids.
The concentration of dextrose in TPN solutions is at least 30%. Trace minerals such as zinc, copper, chromium, and manganese are usually added. Electrolytes and amino acids are part of TPN solutions.
3. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications?
- hyperkalemia and hypercalcemia.
- hyperglycemia and hyperkalemia.
- hypoglycemia and hypercalcemia.
- hyperglycemia and hypokalemia.
Metabolic complications from administration of TPN include hyperglycemia, hypoglycemia, hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia, and hypophosphatemia. Hyperglycemia is the most common complication of TPN. Hypoglycemia can occur when TPN is suddenly withdrawn. Electrolyte deficiencies can occur. The addition of electrolytes is individualized based on the client's metabolism and on the underlying condition.
4. Acetylsalicylic acid is being administered to an adult client. The nurse understands that the most common mechanism of action for nonnarcotic analgesics is their ability to
- target the pain-producing effect of kinins.
- directly affect the central nervous system.
- alter pain perception in the cerebellum.
- inhibit prostaglandin synthesis.
Nonnarcotic analgesics inhibit prostaglandin synthesis. Prostaglandins increase the sensitivity of peripheral pain receptors to endogenous pain-producing substances. There is no direct action on the central nervous system or change in pain perception.
5. An adult has been taking acetylsalicylic acid (ASA) 650 mg four times a day for chronic back pain. The nurse assessing this client knows that a common side effect of high doses of ASA is
- gastrointestinal bleeding.
- retinal detachment.
- paralytic ileus.
- renal failure.
High doses of aspirin are associated with GI bleeding. Renal failure, paralytic ileus, and retinal detachment are not complications associated with aspirin therapy.
6. Ibuprofen (Motrin) is prescribed for an adult with chronic pain. The nurse must teach the client to observe which dietary precaution while taking ibuprofen?
- Omit spinach and other green leafy vegetables from her diet.
- Drink citrus juices daily.
- Eat a high-fiber diet.
- Take the medication with milk.
NSAIDs are very irritating to the GI tract and should always be taken with milk or food to minimize the possibility of bleeding. It is not necessary to add or eliminate food from the diet unless the individual is experiencing some specific food intolerances. Spinach may be omitted from the diet of a person taking coumadin.
7. A 48-year-old woman has just returned to her room after having had a hysterectomy. She has patient-controlled analgesia (PCA). To reduce anxiety regarding receiving adequate pain relief, the client was most likely told that
- comfort will be assessed frequently.
- additional IM medication will be available.
- PCA is almost always effective.
- most therapies are better than frequent IM injections.
Pain is an individual experience. It is important to reassure the client that assessments will be made on a frequent basis and that drug dosages will be adjusted according to the amount of pain the client is perceiving. IM boosts are generally not needed when PCA is in use. PCA is effective when used with clients who are able to follow the directions for use.
8. Which of the following reduces cerebral edema by constricting cerebral veins?
- Mechanical hyperventilation.
- Dexamethasone (Decadron).
- Mannitol (Osmitrol).
Mechanical hyperventilation to reduce CO2 levels to 25 mm Hg produces cerebral vasoconstriction and thereby decreases ICP. Dexamethasone is an anti-inflammatory agent. Mannitol is an osmotic diuretic. While the actions of both drugs will reduce cerebral edema, neither constricts cerebral veins. Ventriculostomy is a surgical procedure where a catheter is placed into a cerebral ventricle to drain excess cerebrospinal fluid.
9. An adult who has a detached retina asks the nurse what may have contributed to the development of his detached retina. The nurse explains that the client at greatest risk for development of a retinal tear usually has
- cranial tumors.
Myopia or nearsightedness is a predisposing factor in the development of a retinal tear. Hypertension, cranial tumors, and sinusitis are not causes of retinal tears unless they result in eye trauma.
10. The nurse is caring for an adult admitted to the coronary care unit with a myocardial infarction. During the second night in the CCU, the client develops congestive heart failure. A Swan-Ganz catheter is inserted to monitor the client for left ventricular function because
- it provides information about pulmonary resistance.
- it measures myocardial oxygen consumption.
- it controls renal blood flow.
- it controls afterload.
The Swan-Ganz catheter measures pulmonary artery and capillary wedge pressures, which are good indicators of pulmonary pathology. The Swan-Ganz catheter does not measure myocardial oxygen consumption and does not control renal blood flow.
11. The nurse is caring for an adult who is being treated for a myocardial infarction. Oxygen is ordered. Administering oxygen to this client is related to which of the following client problems?
- Alteration in heart rate, rhythm, or conduction.
- Alteration in myocardial perfusion.
- Chest pains.
With acute myocardial infarction there is an alteration in myocardial perfusion resulting in a decrease in the amount of oxygen available for tissue perfusion. Therefore, oxygen is administered to improve tissue perfusion in these clients. Nursing interventions for alteration in heart rate, rhythm, or conduction are implemented by monitoring ECGs and administering antiarrhythmics. Anxiety requires nursing implementation of explanation of care as well as environmental control. Pain leads to nursing interventions of analgesia and drug administration.
12. The nurse reading an ECG rhythm strip notes that there are 8 QRS complexes in a 6-second strip. The heart rate is
A regular heart rate is determined by multiplying the number of QRS complexes in 6 seconds (8 QRS complexes) by 10 (because there are 60 seconds in one minute). Therefore the heart rate is 80. This method would not determine an accurate pulse if the client's heart rate was irregular.
13. Mr. Q. is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery
- delivers a precise concentration of oxygen.
- requires humidity during delivery.
- is less traumatic to the respiratory tract.
- mixes room air with oxygen.
Low-flow oxygen systems provide an oxygen concentration that is determined by the amount of air drawn into the system and the dilution of oxygen with room air. There is a considerable variation in the concentration of oxygen that can be delivered to the client. Not all systems require humidification. Oxygen therapy given on a short-term basis is usually not traumatic to the respiratory tract.
14. A 55-year-old man is hospitalized for bladder cancer. He is scheduled for ileal loop surgery to create a urostomy. Which information is most important for the nurse to include in a teaching plan for this client when learning to change his urostomy appliance?
- Use firm pressure to attach the wafer to the skin.
- Change the appliance before going to bed.
- Cut the wafer 1/2 inch larger than the stoma.
- Cleanse the peristomal skin with soap and water.
Cleansing the peristomal skin is critical to maintenance of skin integrity. The appliance should be changed in the morning when urinary drainage can be expected to be scant. A 1/2-inch gap between the stoma and the wafer is too large and encourages skin excoriation. Soap should not be used around the stoma. Firm pressure should not be used.
15. Which nursing intervention best prevents urinary tract infections in a person who has an ileal conduit?
- Changing the appliance every 8 hours.
- Allowing the bag to fill completely.
- Restricting fluids to less than 1000 ml daily.
- Attaching a larger bag at night.
Attaching a larger bag at night helps to prevent reflux of urine into the stoma during a period when the bag is emptied less frequently. Allowing the bag to fill completely will cause the seal to be broken but will not prevent urinary tract infection. Fluids should be encouraged, not restricted, in a client with a urinary stoma. Changing an appliance every 8 hours is too frequent and may cause skin irritation.
16. An elderly man has just returned to the nursing care unit following a transurethral resection. He has a three-way indwelling catheter with continuous bladder irrigation. He tells the nurse he has to void. The most appropriate nursing action is to
- remove the catheter.
- allow him to void around the catheter.
- notify the physician.
- irrigate the catheter.
Blood clots clogging the catheter will produce the sensation of needing to void. Irrigation of the catheter will remove the blood clots allowing the urine to run freely. The client will not be able to void around the catheter because the catheter is inserted snugly into the urethra and the urine drains into the lumen of the catheter. It is not necessary to notify the physician at this point. The catheter may not be removed unless ordered by the physician.
17. Sally, 17 years old, is admitted to the hospital with a diagnosis of acute renal failure. She is oliguric and has proteinuria. Sally asks the nurse, "How long will it be until I start to make urine again?" A correct nursing response would be to tell her that this phase of renal failure will last for approximately
- 3–4 weeks.
- 1–2 days.
- 3–7 days.
- 1–2 weeks.
The oliguric period ranges from 1–2 weeks.
18. The nurse is caring for a person who is admitted in acute renal failure. The appearance of a U wave on the ECG should alert the nurse to check laboratory values for
U waves on an EKG are associated with hypokalemia. Hyperkalemia shows EKG changes of tall tented T waves, widening QRS, and ST segment depression. Hypernatremia is a greater than normal concentration of sodium in the blood caused by excessive loss of water. Clients with hypernatremia may become confused, experience seizures, and lapse into coma. Replacement of water must be done slowly to avoid other electrolyte imbalances. Hyponatremia is a less than normal concentration of sodium in the blood caused by inadequate excretion of water, or by excessive water in the bloodstream. The client may develop water intoxication with confusion and lethargy, progressing to muscle excitability, convulsions, and coma.
19. The nurse is caring for a woman who is on hemodialysis. She has an arteriovenous fistula. Which finding is expected when assessing the fistula?
- Ecchymotic area.
- Enlarged veins.
The leaking of arterial blood into an AV fistula causes the veins to enlarge so they are easier to access for hemodialysis. An AV fistula requires 4–6 weeks to mature before it can be used. Peritoneal dialysis or external shunts may be used while the fistula is maturing. There should not be a marked ecchymotic area. There should be a bounding pulse and a continuous bruit (on auscultation) over the fistula. Redness over the fistula is not an expected finding.
20. Mrs. F. has been diagnosed with rheumatoid arthritis for the past eight years. Her condition is deteriorating despite conservative treatment, and intramuscular gold is prescribed by the physician. When teaching her about gold (chrysotherapy), it is important that the nurse emphasize
- the need to take this drug daily.
- side effects are rare.
- Cushing's syndrome is common.
- improvement may not occur for 3–6 months.
Chrysotherapy often requires a 3- to 6-month period before effects are seen. Cushing's syndrome is associated with steroid therapy, which is also utilized in rheumatoid arthritis. Side effects such as blood dyscrasias and renal damage may occur, and the client must be carefully monitored. Daily doses of this drug are usually not required.
21. A woman who has had rheumatoid arthritis for several years is admitted to the hospital. Upon physical examination of the client, the nurse should expect to find
- Heberden's nodes.
- asymmetric joint involvement.
- small joint involvement.
Small joint involvement is common in rheumatoid arthritis. All of the other symptoms listed (asymmetric joint involvement, Heberden's nodes, and obesity) are symptoms that are seen in osteoarthritis.
22. The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair which of the following nursing measures will best facilitate the resumption of activities for this client?
- Assisting her to sit out of bed in a chair qid.
- Asking her family to visit.
- Arranging for a wheelchair.
- Encouraging the use of an overhead trapeze.
Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Use of the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption of activities. Sitting in a chair would cause too great hip flexion. The client initially needs to be in a low Fowler's position or taking a few steps (as ordered) with the aid of a walker.
23. The nurse is teaching a woman who has a simple goiter. The nurse teaches the client that to enhance glandular function, she should eliminate which of the following foods?
Turnips belong to a classification of foods called exogenous goitrogens. Goitrogens are thyroid-inhibiting substances and therefore should be avoided. Other goitrogens include rutabagas, cabbage, soybeans, peanuts, peaches, peas, strawberries, spinach, and radishes. Corn, milk, and watermelon are not goitrogenic.