NR305 Monitoring for Health Problems Questions and Answers,100% CORRECT

NR305 Monitoring for Health Problems Questions and Answers Question 1 1 / 1 pts A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? Contact the health care provider Place the client in a supine position with the legs flat Document the findings Cover the abdominal wound with a sterile dressing moistened with sterile saline solution Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. Test-Taking Strategy: Note the strategic word “immediate.” Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound dehiscence Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Caregiving, Tissue Integrity HESI Concepts: Caregiving, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby. A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? Obtain a flashlight, gauze, and a curved hemostat Check the client’s blood pressure Continue the assessment Notify the surgeon Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately. Test-Taking Strategy: Note the strategic word, immediate. Noting the words “bright-red blood” will assist in directing you to the correct option. Remember that the presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs after a tonsillectomy and adenoidectomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Collaboration, Clotting HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 644). St. Louis: Saunders. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? Ensuring that the intravenous (IV) line is patent Attaching the client to a cardiac monitor Administering oxygen by way of nasal cannula Preparing the client for a perfusion scan Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the health care provideris notified. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for arterial blood gas determinations drawn. The immediate priority, however, is the administration of oxygen. Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Use the ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions to be taken immediately in the event of pulmonary embolism Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Perfusion, Clotting HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby. A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). Chang the drainage system Reduce the degree of suction being applied Clamp the chest tube Document assessment findings, actions taken, and client response Assess the system for an external air leak Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the health care provider is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test-Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube drainage system. Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? Cover the insertion site with a sterile occlusive dressing Transfer the client back to bed Contact the health care provider Reinsert the chest tube Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the health care provider. The nurse does not reinsert the chest tube. The health care provider will reinsert the chest tube as necessary. Test-Taking Strategy: Note the strategic word “immediate.” Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not trained to insert a chest tube. To select from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site, and recall the complications associated with this occurrence; this will direct you to the correct option. Review the nursing actions to be taken immediately in the event of complications associated with a closed chest tube drainage system Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? Continue suctioning to remove the blood Encourage the client to cough out the bloody secretions Check the degree of suction being applied Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions. Test-Taking Strategy: Note the strategic word, first. Eliminate the options of continuing the suctioning to remove the blood and removing the suction catheter from the nose to begin vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate the option that involves encouraging the client to cough out the bloody secretions, because it is unlikely that the client will be able to do so. Review the nursing actions to be taken immediately in the event of a complication during suctioning Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 629, 635). St. Louis: Mosby. A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first? Contact the health care provider Disconnect the suction source from the catheter Administer a bronchodilator Call a code Rationale: 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 immediately disconnects the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The health care provider is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved. Test-Taking Strategy: Note the strategic word “first.” Eliminate the option of administering a bronchodilator, because this action requires a health care provider’s prescription. To select from the remaining options, visualize the situation presented in the question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea will direct you to the correct option. Review the nursing actions to be taken immediately in the event of a complication during suctioning Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 574-575). St. Louis: Saunders. A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? Contact the health care provider Check the client’s blood pressure and heart rate Connect a new drainage system to the client’s chest tube Check for kinks in the drainage system Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs of respiratory distress or mediastinal shift; and if such signs are noted, the 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 once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client’s chest tube. Test-Taking Strategy: Note strategic word “first.” Focusing on the subject, a lack of chest tube drainage, will direct you to the correct option. Review unexpected outcomes and related interventions in the care of a chest tube drainage system Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 637). St. Louis: Saunders. A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? Increase the rate of the IV infusion Administer a 250-mL bolus of normal saline solution (0.9%) Call the health care provider Check the client’s overall intake and output record Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a 250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the health care provider. The health care provider is called once the nurse has gathered all necessary assessment data, including the overall fluid status and vital signs. Test-Taking Strategy: Note the strategic word “first.” Try to visualize the situation and use the steps of the nursing process to answer the question. The correct option addresses the process of assessment. Eliminate increasing the rate of the IV infusion and administering a 250-mL bolus of normal saline (0.9%), because each requires a health care provider’s prescription. In this situation, the nurse needs to gather additional information before contacting the health care provider. Review unexpected outcomes after surgery and priority nursing interventions in the event of such outcomes Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 289-290). St. Louis: Saunders. A nurse is getting a 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 Check the oxygen saturation level Have the client take some deep breaths Check the client’s blood pressure Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken. Test-Taking Strategy: Note the strategic word “first.” Note the relationship between the subject of the question (the client becomes dizzy) and the correct answer. Review unexpected outcomes after surgery and the priority nursing interventions in the event of such outcomes Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., pp. 356- 357). St. Louis: Mosby. A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? Check the hourly urine output Check the IV site for infiltration Place the client in a modified Trendelenburg position Call the health care provider Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position (flat with the legs elevated) to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure. The nurse calls the health care provider, verifies the client’s blood volume status by assessing urine output, and ensures that the IV infusion is proceeding without complications. Test-Taking Strategy: Note the strategic word “first.” Use the ABCs (airway, breathing, circulation). The correct option addresses the client’s circulatory status. Review the nursing interventions to be taken immediately in the event of postoperative shock Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 818). St. Louis: Saunders. A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? The client’s lung sounds The client’s vital signs The amount of drainage The 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 or incision in the pulmonary pleura, which requires health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried 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. Test-Taking Strategy: Note the strategic word “first” and focus on the data in the question. Recalling that a constant bubbling in the water seal chamber could indicate a leak in the system will direct you to the correct option. Review care of the client with a closed chest tube drainage system Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 660). St. Louis: Mosby. A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? Veal Cheese Steak Oranges Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in vitamin C. Meats are high in protein. Dairy products are high in calcium. Test-Taking Strategy: Eliminate steak and veal first because they are comparable or alike in that they are meats. To select from the remaining options, recall that cheese is high in calcium, not vitamin C; this will direct you to the correct option. Review foods high in vitamin C Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Perioperative Care Giddens Concepts: Client Education, Nutrition HESI Concepts: Teaching and Learning/Patient Education, Nutrition References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 299-300). St. Louis: Saunders. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 450-451). St. Louis: Mosby. A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink? Straw Napkin Suction equipment Oxygen saturation monitor Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nurse checks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort. Test-Taking Strategy: The subject of the question is protecting the client’s gag and swallow reflexes. Use the ABCs (airway, breathing, and circulation) to answer this question. The correct option helps maintain airway clearance. Review care of the client who has recently undergone surgery and is beginning a clear liquid diet. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Perioperative Care Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 360). St. Louis: Mosby. A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? Nausea and vomiting Incisional pain Paralytic ileus Urine retention Rationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is not used to treat any of the problems identified in the other options. Test-Taking Strategy: Note the subject, the action and use of ondansetron. To answer this question accurately, it is necessary to know the classification of this medication. Focusing on the clinical setting identified in the question should narrow your choices to nausea and vomiting and incisional pain. To correctly select from these two options, it is necessary to know that ondansetron is an antiemetic. Review the action of ondansetron Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Caregiving, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Comfort Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 889-890) St. Louis: Saunders. A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? Complaints of feeling sweaty Correct Answer Complaints of dry mouth Pupil constriction Increased urine output Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry mouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect. Test-Taking Strategy: Focus on the subject, the side effects of scopolamine. Recalling the classification of this medication and that this medication dries body secretions will direct you to the correct option. Review the expected side effects of scopolamine Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts: Assessment, Cellular Regulation Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 1092) St. Louis: Saunders. A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? Administering all daily medications Ensuring that the client has voided Verifying that the client has not eaten for the last 24 hours Practicing postoperative breathing exercises Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours before surgery, not 24 hours. The time of transfer to the operating room is not the time to practice breathing exercises. This should have been done earlier. Test-Taking Strategy: Note the words “at this time.” Eliminate the option that involves administering all daily medications because of the close-ended word “all.” Eliminate the option that involves verifying that the client has not eaten for the last 24 hours because of the words “last 24 hours.” To select from the remaining options, focus on the words “at this time”; this will direct you to the correct option. Remember that the client is likely to be anxious at this time, meaning that it would be inappropriate to practice breathing exercises. Review preoperative client care measures Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Caregiving, Safety HESI Concepts: Comfort, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 327). St. Louis: Mosby. A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? Assess the patency of the airway Check the dressing for bleeding Check tubes and drains for patency Assess the vital signs to compare them with preoperative measurements Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then performs an assessment of cardiovascular function, the condition of the surgical site, the patency of tubes and drains for patency, and the function of the central nervous system. If the airway is not patent, immediate measures must be taken to help ensure the survival of the client. Test-Taking Strategy: Note the strategic word, first. Use the ABCs (airway, breathing, and circulation). Airway patency is the priority. The incorrect options are all nursing actions that should be performed after a patent airway has been established. Review priority nursing assessments in the client who has undergone surgery Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 350). St. Louis: Mosby. A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? 89% 95% 100% 85% Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected reading is at least 95%. Therefore the other options are incorrect. Readings of 85% and 89% are lower than what is desired in the postoperative period. A level of 100% is most desirable, but the level should remain at least 95% Test-Taking Strategy: Note the information in the question and that the client is without a history of respiratory disease. Familiarity with the pulse oximeter and normal readings is needed to answer this question. Noting the word “above” in the question will help you answer correctly. Review the purpose and expected results of pulse oximetry. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., pp. 479, 491). St. Louis: Mosby. Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 101-102). St. Louis: Mosby. A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply. Hematocrit 30% (0.30) Platelets 210× 103/μL (210 × 109/L) Sodium 141 mEq/L (141 mmol/L) Hemoglobin 8.9 g/dL (89 g/L) Serum creatinine 0.8 mg/dL (70 μmol/L) Rationale: Routine screening tests include complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood cell count includes the hemoglobin and hematocrit analysis. All of these values are within their normal ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit levels, the surgery may be postponed by the surgeon. The normal hemoglobin level for a male ranges from 13.2 to 17.3 g/dL (132-173 g/L) and for a female, 11.7 to 15.5 g/dL (117-155 g/L). The normal hematocrit for a male ranges from 39% to 50% ( 0.39-0.50) and for a female, 35% to 47% ( 0.35-0.47). Test-Taking Strategy: Note the word “abnormal” in the question and focus on the subject, laboratory results that could necessitate the postponement of surgery. Recalling the normal values for the laboratory studies identified in the options will direct you to the correct ones. Review these normal laboratory values Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Laboratory Values Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 325). St. Louis: Mosby. A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client’s medical history? Chronic airway limitation Pancreatitis Pacemaker insertion Type 1 diabetes mellitus Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is conducted to determine whether any such metal objects, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the client. These may heat up in the magnetic field generated by the MRI device, become dislodged, or malfunction during the procedure. The other medical problems listed do not pose a risk or contraindication for this procedure. Test-Taking Strategy: Note that each of the incorrect options are comparable or alike and are medical disorders. The correct option is the name of a procedure in which a device is implanted into the client. Remember that it is crucial to ensure that there are no metal objects in the vicinity of the MRI machine. Review contraindications to MRI Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Assessment, Safety References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1352). St. Louis: Mosby. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 1101). St. Louis: Mosby. A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? Sitting up in a recliner with the feet elevated Semi-Fowler Flat Side-lying, with the head of the bed elevated Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other options are incorrect. Test-Taking Strategy: Note that the incorrect options are comparable or alike in that they all involve elevation of the client’s head. Review care of the client after lumbar puncture Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Diagnostic Tests and Procedures Giddens Concepts: Caregiving, Intracranial Regulation HESI Concepts: Caregiving, Intracranial Regulation Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1352). St. Louis: Mosby. A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after- care for this client? Encouraging fluid intake Holding all medications for at least 2 hours Administering a laxative Maintaining the client on strict bed rest Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye. Medications do not have to be withheld. There is no reason to administer a laxative; also, a health care provider’s prescription is needed for this intervention. Test-Taking Strategy: Focus on the subject, aftercare following CT scanning. Note the words “contrast medium” in the question. Recalling the importance of flushing the dye from the system after this procedure will direct you to the correct option. Review care after a CT scan Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Diagnostic Tests and Procedures Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 1055). St. Louis: Mosby. A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? “It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.” “I didn’t shampoo my hair.” “I ate breakfast this morning.” “I didn’t take my anticonvulsant today.” Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring that the client’s hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld. Test-Taking Strategy: Use your knowledge of the EEG procedure to answer the question and note the strategic words “needs additional preparation.” These words indicate a negative event query and the need to select the incorrect client statement. Recalling the purpose of an EEG and the anatomical location of this test will direct you to the correct option. Review preparation for an EEG Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamentals of Care: Diagnostic Tests and Procedures Giddens Concepts: Client Education, Intracranial Regulation HESI Concepts: Teaching and Learning/Patient Education, Intracranial Regulation Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 922-923). St. Louis: Saunders. Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? 12.8 mg/dL (762.1 μmol/L) 8.9 mg/dL (529.9 μmol/L) 4.4 mg/dL (262 μmol/L) 1.7 mg/dL (101.2 μmol/L) Rationale: The normal range for uric acid is 4.4 to 7.6 mg/dL (262 to 452 μmol/L)for males and 2.3 to 6.6 mg/dL (137 to 393 μmol/L)for females. Therefore the other options are incorrect. Test-Taking Strategy: Focus on the subject, the normal uric acid reference range for a male. To answer this question correctly, you must be familiar with the normal range of values for serum uric acid. Review the normal reference range for uric acid for males and females Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Laboratory Values Giddens Concepts: Cellular Regulation, Elimination HESI Concepts: Cellular Regulation, Elimination Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1057). St. Louis: Mosby. Question 26 1 / 1 pts A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? To report to the health care provider the development of fever or redness and heat at the site To resume full activity the next day To keep the shoulder completely immobilized for the rest of the day Not to eat or drink anything until the next morning Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat at the site should be reported to the health care provider. The client may resume the usual diet immediately. The arm does not have to be completely immobilized once sensation has returned, but the client is usually encouraged to refrain from strenuous activity for at least a few days. Test-Taking Strategy: Focus on the subject, client instructions after arthroscopy of the shoulder. Eliminate keeping the shoulder completely immobilized for the rest of the day and resuming full activity the next day, because they represent extremes of activity variations. To select from the remaining options, remember that the client is always taught to report signs and symptoms of infection to the health care provider. Review client instructions after arthroscopy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal Giddens Concepts: Client Education, Mobility HESI Concepts: Teaching and Learning/Patient Education, Mobility References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 331). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1499, 1535). St. Louis: Mosby. Question 27 1 / 1 pts A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? The test will need to be confirmed with the use of a Western blot A positive test is a normal result and does not mean that the client is infected with HIV HIV infection has been confirmed The client probably has an opportunistic infection Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be confirmed with the use of the Western Blot. The other options are incorrect. Test-Taking Strategy: Read each option carefully and focus on the subject, that the test result is positive. Recalling that an ELISA test is an HIV antibody-screening test and that a positive result must be confirmed with the use of the Western blot will direct you to the correct option. Review interpretations of the results of an ELISA test Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Immune Giddens Concepts: Client Education, Immunity HESI Concepts: Teaching and Learning/Patient Education, Immunity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., p. 369). St. Louis: Saunders. A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? The need for antiretroviral therapy An effective response to the treatment for HIV The need to discontinue antiretroviral therapy Improvement in the client Rationale: The normal CD4+ count is between 500 to 1,500 cells per cubic millimeter of blood.Antiretroviral therapy is recommended when the CD4+ count is less than 500 cells per cubic millimeter of bloodor below 25%, or when the client shows symptoms of HIV. The other options are incorrect. Test-Taking Strategy: Eliminate the incorrect options because they are comparable or alike in that they indicate a positive response to treatment. Review the CD4+ count and the interpretation of its results. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Adult Health/Immune Giddens Concepts: Cellular Regulation, Immunity HESI Concepts: Cellular Regulation, Immunity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient- centered collaborative care. (7th ed., pp. 368-369). St. Louis: Saunders. A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? Restricting fluid intake for the first 24 hours Correct Answer Periodically testing the urine for occult blood Avoiding the administration of opioid analgesics Having the client ambulate in the room and hall for short distances Rationale: After renal biopsy, bed rest is maintained and the client’s vital signs and puncture site are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid analgesics are often needed to manage the renal colic pain that some clients feel after this procedure. Test-Taking Strategy: Focus on the subject, postprocedure care following renal biopsy. Think about what a biopsy entails. Recalling that pain and bleeding are potential concerns after this procedure will direct you to the correct option. Review care of the client after renal biopsy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Renal and Urinary Giddens Concepts: Care Coordination, Clotting HESI Concepts: Nursing Interventions, Perfusion-Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1061). St. Louis: Mosby. A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? Discarding the last voided specimen at the end of the collection time Asking the client to void, discarding the specimen, and noting the start time Keeping the specimen at room temperature Saving the first urine specimen collected at the start time Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The collection should be refrigerated or placed on ice to help prevent changes in urine composition. Test-Taking Strategy: Focus on the subject, collecting collecting a 24-hour urine specimen. Think about the purpose and procdure of collecting a specimen. Recalling that the 24-hour urine collection is a timed quantitative determination will assist you in identifying the correct option. Review the procedure for collecting a 24-hour urine specimen Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Diagnostic Tests and Procedures Giddens Concepts: Caregiving, Elimination HESI Concepts: Nursing Interventions, Elimination Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1057). St. Louis: Mosby. A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? Administering a sedative Administering an oral preparation of radiopaque dye Encouraging fluid intake Questioning the client about allergies to iodine or shellfish Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction, manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is injected intravenously. The client may or may not receive premedication. Nothing-by-mouth status is generally imposed after midnight on the day before the test. Test-Taking Strategy: Note the strategic words, most important. Noting the word “intravenous” in the name of the test indicates that a dye will be injected. This will help direct you to the correct option. Review the priority assessments in preprocedure care for an IVP. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Diagnostic Tests and Procedures Giddens Concepts: Caregiving, Safety HESI Concepts: Nursing Interventions, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1058). St. Louis: Mosby. A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? Increased temperature Infection at the site Bleeding Renal colic Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic. Test-Taking Strategy: Eliminate the options of increased temperature and infection at the site first because they are comparable or alike. To choose between the remaining options, recall that the information in the question is not indicative of renal colic. Review the complications associated with renal biopsy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Renal and Urinary Giddens Concepts: Clinical Judgment, Pain HESI Concepts: Clinical Decision-Making/Clinical Judgment, Comfort-Pain Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1061). St. Louis: Mosby. A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? Respiratory rate of 18 breaths/min Urine output of 40 mL/hr Pallor and coolness of the right leg Blood pressure of 118/76 mm Hg Rationale: Complications of renal angiography include allergic reaction to the dye, dye- induced renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and embolism. The nurse detects these complications by monitoring the client for signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and signs of diminished circulation to the affected leg. The incorrect options are normal findings. Test-Taking Strategy: Note the subject “a complication of the procedure,” which should tell you that the correct option is an abnormal assessment finding. Eliminate the incorrect options, because they are normal findings. Pallor and coolness indicate thrombosis or hematoma and should be further assessed and reported. Review the signs of complications after renal angiography Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Renal and Urinary Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion-Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 1058). St. Louis: Mosby. A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal? An absence of protein The presence of ketones pH of 6.0 Specific gravity of 1.018 Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present. Test-Taking Strategy: Focus on the subject, an abnormal finding in the urinalysis. The words “the presence of” should direct you to the correct option. Review normal urinalysis findings Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Renal and Urinary Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Assessment, Elimination Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1056, 1062). St. Louis: Mosby. A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? It is necessary to lie quietly on a hard x-ray table for about 4 hours The client may have feelings of warmth or flushing during the procedure The procedure is performed in the operating room The room is bright and well lit, and it is best to keep the eyes closed Rationale: The nurse tells the client about to undergo cardiac catheterization room that the procedure is performed in a darkened room in the radiology department. A local anesthetic is used, so there is little or no pain with catheter insertion. The procedure may take as long as 2 hours, during which time the client may feel various sensations including a feeling of warmth or flushing, with catheter passage and dye injection. The x-ray table is hard and may be tilted periodically to obtain the best possible views. Test-Taking Strategy: Focus on the subject, the cardiac catheterization procedure. Recalling that this is a diagnostic procedure will help you eliminate the option in which the nurse tells the client that the procedure is performed in the operating room. The duration of the procedure (4 hours) identified in this incorrect option should cause you to eliminate it, and the use of the words “bright and well lit” indicate an incorrect option. Review the procedure for cardiac catheterization Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Giddens Concepts: Client Education, Perfusion HESI Concepts: Teaching and Learning/Patient Education, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 703). St. Louis: Mosby. A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? Imposing nothing-by-mouth (NPO) status for 4 hours Asking the client about a history of allergy to iodine or shellfish Correct Answer Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Asking the client to sign an informed consent form Rationale: In echocardiography, ultrasound is used to evaluate the heart’s structure and motion. It is a noninvasive, risk-free, pain-free test that involves no special preparation and is commonly performed at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. The other options are incorrect. Test-Taking Strategy: Focus on the subject, preparing the client for an echocardiogram. Recalling that echocardiography involves the use of ultrasound and that ultrasound is noninvasive, safe, and painless should help you eliminate the incorrect options. Review echocardiogram. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts:Clinical Decision Making/Clinical Judgment, Nursing Intervention Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 701). St. Louis: Mosby. A nurse in a health care provider’s office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? Avoid consuming caffeine for 30 minutes before the procedure Eat a small meal just before the procedure Wear comfortable rubber-soled shoes such as sneakers Wear sweatpants and a heavy sweatshirt Rationale: The client should wear comfortable rubber-soled, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement. The client should be NPO after bedtime, or for a minimum of 2 hours before the test, and should avoid tobacco, alcohol, and caffeine on the day of the test. Test-Taking Strategy: Focus on the subject, client teaching for an exercise stress test. Eliminate options that could interfere with test results, such as digestion, alcohol, caffeine, smoking, and restrictive or uncomfortable clothing. This will direct you to the correct option. Review client teaching for exercise stress testing. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Education, Clinical Judgment HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., p. 701). St. Louis: Mosby. A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. Instructing the client to enclose the monitor in plastic wrap before taking a bath Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless Telling the client to rest as much as possible during the next 24 hours Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and symptoms A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? Decreasing pulse Falling central venous pressure (CVP) Rising blood pressure Distant muffled heart sounds Rationale: After effective pericardiocentesis, an increase in blood pressure and a decrease in CVP are expected. The pulse may slow because less cardiac work is needed to produce adequate cardiac output. Distant muffled heart sounds that were noted before the test should become clear with effective pericardiocentesis. A return of distant muffled heart sounds indicates returning pericardial effusion and possible tamponade. Test-Taking Strategy: Focus on the subject, recurring cardiac tamponade. This tells you that the correct option is a symptom of the original problem, cardiac tamponade. Recalling the signs of cardiac tamponade will direct you to the correct option. Review these signs of cardiac tamponade. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts:Clinical Decision Making/Clinical Judgment, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th ed., pp. 815- 817). St. Louis: Mosby. A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. Used a cuff with a rubber bladder that encircles at least 60% of the limb Measuring the BP after the client reports that he just drank a cup (236 ml) of coffee. Allowing the client to talk as the blood pressure is being measured Measuring the BP after the client has sat quietly for 5 minutes Having the client sit with the arm bared and supported at heart level Rationale: The client should not smoke tobacco or drink a beverage containing caffeine for at least 30 minutes before having the BP measured. The bladder of the cuff should encircle at least 80% of the limb being measured. The client should be seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should rest quietly for 5 minutes before the reading is taken. Test-Taking Strategy: Focus on the subject, actions that would interfere with accurate BP measurement. Visualizing this procedure and reading each option carefully will assist you in eliminating the incorrect options. Review the principles related to blood pressure measurement. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Leadership and Management Giddens Concepts: Clinical Judgment, Leadership HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 93, 98). St. Louis: Mosby. A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. Assessing