When educating a client C
after a total Rationale: Neck breathers carry a medical alert
laryngectomy, which card that notifies health care personnel of the need
instruction would be to use mouth to stoma breathing in the event of a
most important for the cardiac arrest in this client. Mouth to mouth
nurse to include in the resuscitation will not establish a patent airway.
discharge teaching? Options A and D are not necessary. There are
A. Recommend that the many alternative means of communication for
client carry suction clients who have had a laryngectomy; dependence
equipment at all times. on writing messages is probably the least effective.
B. Instruct the client to
have writing materials
with him at all times.
C. Tell the client to carry
a medical alert card that
explains his condition.
D. Caution the client not
to travel outside the
United States alone.
The nurse receives the D
client's next scheduled Rationale: Only regular insulin is administered by
bag of TPN labeled with the IV route, so the TPN solution containing NPH
the additive NPH insulin. insulin should be returned to the pharmacy.
Which action should the Options A, B, and C are not indicated because the
nurse implement? solution should not be administered.
A. Hang the solution at
the current rate.
B. Refrigerate the
solution until needed.
C.Prepare the solution
with new tubing.
D.Return the solution to
the pharmacy.
A postoperative client C
receives a Schedule II Rationale: Administration of a Schedule II opioid
opioid analgesic for pain. analgesic can result in respiratory depression,
Which assessment which requires immediate intervention by the nurse
finding requires the most to prevent respiratory arrest. Options A, B, and D
immediate intervention
,by the nurse? require action by the nurse but are of less priority
A. Hypoactive bowel than option C.
sounds with abdominal
distention
B. Client reports
continued pain of 8 on a
10-point scale
C. Respiratory rate of 12
breaths/min, with O2
saturation of 85%
D. Client reports nausea
after receiving the
medication
A client is placed on a A
mechanical ventilator Rationale:To increase the client's tolerance of
following a cerebral endotracheal intubation and/or mechanical
hemorrhage, and ventilation, a skeletal muscle relaxant such as
vecuronium bromide, vecuronium is usually prescribed. Option A is a
0.04 mg/kg every 12 serious outcome because the client cannot
hours IV, is prescribed. communicate his or her needs. Although this client
What is the priority might also experience option D, it is not a priority
nursing diagnosis for this when compared with option A. Infection is not
client? related to increased intracranial pressure. The
A. Impaired respirator will ensure that the lungs are expanded,
communication related so option C is incorrect.
to paralysis of skeletal
muscles
B. High risk for infection
related to increased
intracranial pressure
C. Potential for injury
related to impaired lung
expansion
D. Social isolation
related to inability to
communicate
A family member was B
taught to suction a Rationale:Option B indicates correct technique for
client's tracheostomy performing suctioning. Suction pressure should be
prior to the client's between 80 and 120 mm Hg, not 190 mm Hg. The
discharge from the catheter should be withdrawn 1 to 2 cm at a time
hospital. Which with intermittent, not continuous, suction. Option D
observation by the nurse introduces pathogens unnecessarily into the
indicates that the family tracheobronchial tree.
member is capable of
,correctly performing the
suctioning technique?
A. Turns on the
continuous wall suction
to 190 mm Hg.
B. Inserts the catheter
until resistance or
coughing occurs.
C. Withdraws the
catheter while
maintaining suctioning.
D. Reclears the
tracheostomy after
suctioning the mouth.
A client is diagnosed A
with an acute small Rationale:A sudden increase in temperature is an
bowel obstruction. Which indicator of peritonitis. The nurse should notify the
assessment finding health care provider immediately. Options B, C,
requires the most and D are also findings that require intervention by
immediate intervention the nurse but are of less priority than option A.
by the nurse? Option B may indicate a hypertensive condition but
A. Fever of 102° F is not as acute a condition as peritonitis. Option C
B. Blood pressure of is an expected finding in clients with small bowel
150/90 mm Hg obstruction and may require medication. Option D
C. Abdominal cramping indicates probable fluid volume deficit, which
D. Dry mucous requires fluid volume replacement.
membranes
In assessing a client C
diagnosed with primary Rationale: Clients with primary aldosteronism
aldosteronism, the nurse exhibit a profound decline in serum levels of
expects the laboratory potassium; hypokalemia; hypertension is the most
test results to indicate a prominent and universal sign. The serum sodium
decreased serum level level is normal or elevated, depending on the
of which substance? amount of water resorbed with the sodium. Option
A. Sodium B is influenced by parathyroid hormone (PTH).
B. Phosphate Option D is not affected by primary aldosteronism.
C. Potassium
D. Glucose
During assessment of a A
client in the intensive Rationale: The client is exhibiting symptoms of
care unit, the nurse cardiac tamponade, a collection of fluid in the
, notes that the client's pericardial sac that results in a reduction in cardiac
breath sounds are clear output, which is a potentially fatal complication of
on auscultation, but pericarditis. Treatment for tamponade is a
jugular vein distention pericardial tap. Lasix IV is not indicated for
and muffled heart treatment of pericarditis. Because the client's
sounds are present. breath sounds are clear, option C is not a priority.
Which intervention Fluids are frequently increased in the initial
should the nurse treatment of tamponade to compensate for the
implement? decrease in cardiac output, but this is not the same
A. Prepare the client for priority as option A.
a pericardial tap.
B. Administer
intravenous furosemide
(Lasix).
C. Assist the client to
cough and breathe
deeply.
D. Instruct the client to
restrict oral fluid intake.
A central venous D
catheter has been Rationale:Medication can be administered via a
inserted via a jugular central line without additional IV fluids. The line
vein, and a radiograph should first be flushed with a normal saline solution
has confirmed to ensure patency. Insufficient evidence exists on
placement of the the effectiveness of flushing catheters with heparin.
catheter. A prescription Option A will not affect the decision to administer
has been received for a the medication and is not a priority. Administration
medication STAT, but IV of the medication STAT is of greater priority than
fluids have not yet been option B.
started. Which action
should the nurse take
prior to administering the
prescribed medication?
A. Assess for signs of
jugular venous
distention.
B. Obtain the needed
intravenous solution.
C. Flush the line with
heparinized solution.
D. Flush the line with
normal saline.
Which data would the C
nurse expect to find Rationale: In older adults, the protein found in
when reviewing urine slightly rises, probably as a result of kidney
after a total Rationale: Neck breathers carry a medical alert
laryngectomy, which card that notifies health care personnel of the need
instruction would be to use mouth to stoma breathing in the event of a
most important for the cardiac arrest in this client. Mouth to mouth
nurse to include in the resuscitation will not establish a patent airway.
discharge teaching? Options A and D are not necessary. There are
A. Recommend that the many alternative means of communication for
client carry suction clients who have had a laryngectomy; dependence
equipment at all times. on writing messages is probably the least effective.
B. Instruct the client to
have writing materials
with him at all times.
C. Tell the client to carry
a medical alert card that
explains his condition.
D. Caution the client not
to travel outside the
United States alone.
The nurse receives the D
client's next scheduled Rationale: Only regular insulin is administered by
bag of TPN labeled with the IV route, so the TPN solution containing NPH
the additive NPH insulin. insulin should be returned to the pharmacy.
Which action should the Options A, B, and C are not indicated because the
nurse implement? solution should not be administered.
A. Hang the solution at
the current rate.
B. Refrigerate the
solution until needed.
C.Prepare the solution
with new tubing.
D.Return the solution to
the pharmacy.
A postoperative client C
receives a Schedule II Rationale: Administration of a Schedule II opioid
opioid analgesic for pain. analgesic can result in respiratory depression,
Which assessment which requires immediate intervention by the nurse
finding requires the most to prevent respiratory arrest. Options A, B, and D
immediate intervention
,by the nurse? require action by the nurse but are of less priority
A. Hypoactive bowel than option C.
sounds with abdominal
distention
B. Client reports
continued pain of 8 on a
10-point scale
C. Respiratory rate of 12
breaths/min, with O2
saturation of 85%
D. Client reports nausea
after receiving the
medication
A client is placed on a A
mechanical ventilator Rationale:To increase the client's tolerance of
following a cerebral endotracheal intubation and/or mechanical
hemorrhage, and ventilation, a skeletal muscle relaxant such as
vecuronium bromide, vecuronium is usually prescribed. Option A is a
0.04 mg/kg every 12 serious outcome because the client cannot
hours IV, is prescribed. communicate his or her needs. Although this client
What is the priority might also experience option D, it is not a priority
nursing diagnosis for this when compared with option A. Infection is not
client? related to increased intracranial pressure. The
A. Impaired respirator will ensure that the lungs are expanded,
communication related so option C is incorrect.
to paralysis of skeletal
muscles
B. High risk for infection
related to increased
intracranial pressure
C. Potential for injury
related to impaired lung
expansion
D. Social isolation
related to inability to
communicate
A family member was B
taught to suction a Rationale:Option B indicates correct technique for
client's tracheostomy performing suctioning. Suction pressure should be
prior to the client's between 80 and 120 mm Hg, not 190 mm Hg. The
discharge from the catheter should be withdrawn 1 to 2 cm at a time
hospital. Which with intermittent, not continuous, suction. Option D
observation by the nurse introduces pathogens unnecessarily into the
indicates that the family tracheobronchial tree.
member is capable of
,correctly performing the
suctioning technique?
A. Turns on the
continuous wall suction
to 190 mm Hg.
B. Inserts the catheter
until resistance or
coughing occurs.
C. Withdraws the
catheter while
maintaining suctioning.
D. Reclears the
tracheostomy after
suctioning the mouth.
A client is diagnosed A
with an acute small Rationale:A sudden increase in temperature is an
bowel obstruction. Which indicator of peritonitis. The nurse should notify the
assessment finding health care provider immediately. Options B, C,
requires the most and D are also findings that require intervention by
immediate intervention the nurse but are of less priority than option A.
by the nurse? Option B may indicate a hypertensive condition but
A. Fever of 102° F is not as acute a condition as peritonitis. Option C
B. Blood pressure of is an expected finding in clients with small bowel
150/90 mm Hg obstruction and may require medication. Option D
C. Abdominal cramping indicates probable fluid volume deficit, which
D. Dry mucous requires fluid volume replacement.
membranes
In assessing a client C
diagnosed with primary Rationale: Clients with primary aldosteronism
aldosteronism, the nurse exhibit a profound decline in serum levels of
expects the laboratory potassium; hypokalemia; hypertension is the most
test results to indicate a prominent and universal sign. The serum sodium
decreased serum level level is normal or elevated, depending on the
of which substance? amount of water resorbed with the sodium. Option
A. Sodium B is influenced by parathyroid hormone (PTH).
B. Phosphate Option D is not affected by primary aldosteronism.
C. Potassium
D. Glucose
During assessment of a A
client in the intensive Rationale: The client is exhibiting symptoms of
care unit, the nurse cardiac tamponade, a collection of fluid in the
, notes that the client's pericardial sac that results in a reduction in cardiac
breath sounds are clear output, which is a potentially fatal complication of
on auscultation, but pericarditis. Treatment for tamponade is a
jugular vein distention pericardial tap. Lasix IV is not indicated for
and muffled heart treatment of pericarditis. Because the client's
sounds are present. breath sounds are clear, option C is not a priority.
Which intervention Fluids are frequently increased in the initial
should the nurse treatment of tamponade to compensate for the
implement? decrease in cardiac output, but this is not the same
A. Prepare the client for priority as option A.
a pericardial tap.
B. Administer
intravenous furosemide
(Lasix).
C. Assist the client to
cough and breathe
deeply.
D. Instruct the client to
restrict oral fluid intake.
A central venous D
catheter has been Rationale:Medication can be administered via a
inserted via a jugular central line without additional IV fluids. The line
vein, and a radiograph should first be flushed with a normal saline solution
has confirmed to ensure patency. Insufficient evidence exists on
placement of the the effectiveness of flushing catheters with heparin.
catheter. A prescription Option A will not affect the decision to administer
has been received for a the medication and is not a priority. Administration
medication STAT, but IV of the medication STAT is of greater priority than
fluids have not yet been option B.
started. Which action
should the nurse take
prior to administering the
prescribed medication?
A. Assess for signs of
jugular venous
distention.
B. Obtain the needed
intravenous solution.
C. Flush the line with
heparinized solution.
D. Flush the line with
normal saline.
Which data would the C
nurse expect to find Rationale: In older adults, the protein found in
when reviewing urine slightly rises, probably as a result of kidney
