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

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 position. 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 co