Fluid, Electrolyte, and Acid-Base Balance Learning Outcomes Discuss the function, distribution, movement, and regulation of fluids

s and electrolytes in the body. Describe the regulation of acidbase balance in the body, including the roles of the lungs, the kidneys and buffers. Identify factors affecting normal body fluid, electrolyte, and acidbase balance. Discuss the risk factors for and the causes and effects of fluid, electrolyte, and acidbase imbalances. Collect assessment data related to the clients fluid, electrolyte, and acidbase balances. Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid base balance. Teach clients measures to maintain fluid and electrolyte balance. Implement measures to correct imbalances of fluids and electrolytes or acids and bases such as enteral or parenteral replacements and blood transfusions. Evaluate the effect of nursing and collaborative interventions on the clients fluid, electrolyte, or acidbase balance.

A delicate (fragile) balance of fluids, electrolytes, and acids and bases is maintained in the body. This balance d epends on multiple physiologic processes that regulate fluid intake and output and the movement of water and substances dissolved in it between body compartments.

Water is vital to health and normal cellular function. It serves as a medium for metabolic reactions within the c ells; a transporter for nutrients, waste products, and other substances; a lubricant; an insulator; a shock absorb er; and one means of regulating and maintaining body temperature.

The bodys fluid is divided into two major compartments: intracellular and extracellular. Intracellular fluid (ICF) is found within the cells, and extracellular fluid (ECF) is found outside the cells.

The two main compartments of the ECF are intravascular fluid (plasma) and interstitial fluid (surrounds the cell s). Other compartments of ECF include lymph and transcellular fluids such as cerebrospinal, pericardial, pancre atic, pleural, intraocular, biliary, peritoneal, and synovial fluids. Intracellular fluid is vital to normal cell function ing.

It contains solutes such as oxygen, electrolytes, and glucose, and it provides a medium in which metabolic proc esses of the cell take place. Extracellular fluid is the transport system that carries nutrients to and waste produc ts from the cells.

Fluids and electrolytes move among the body compartments by osmosis, diffusion, filtration, and active transp ort. The volume and composition of body fluids is regulated through several homeostatic mechanisms: the kid neys, the endocrine system, the cardiovascular system, the lungs, and the gastrointestinal system.

The antidiuretic hormone (ADH), also called arginine vasopressin (AVP), the renin-angiotensinaldosterone system.

Movement of Body Fluids Osmosis Diffusion Filtration Active transport

Osmosis: Water molecules move from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane.

Diffusion: The movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration.

Schematic of filtration pressure changes within a capillary bed. On the arterial side, arterial blood pressure exceeds colloid osmotic pressure, so that water and dissolved substances move out of the capillary into the interstitial space. On the venous side, venous blood pressure is less than colloid osmotic pressure, so that the water and dissolved substances move into the capillary.

Regulating Body Fluids Fluid intake o Thirst Fluid output o Urine o Insensible loss o Feces

Maintaining homeostasis o Kidneys o ADH o Renin-angiotensin-aldosterone system

ECF and ICF contain ions (charged particles). Anions are negative ions and cations are positive ions called electr olytes. The number of cations and anions in should be equal.

The principal electrolytes in the ECF are sodium, chloride, and bicarbonate. Other electrolytes such as potassiu m, calcium, and magnesium but in much smaller quantities.

Plasma and interstitial fluids (major components of ECF) contain essentially the same electrolytes and solutes with the exception of proteins, which are plentiful in the plasma.

The primary electrolytes in the ICF are potassium, magnesium, phosphate, and sulfate. As in ECF, other electrol ytes are present within the cells, but in smaller concentrations.

Distribution of Body Fluids

Regulating Electrolytes Sodium Potassium Calcium Magnesium Chloride Phosphate Bicarbonate

Regulation Acid-Base Balance

An important part of regulating the chemical balance or homeostasis of body fluids is regulating their acidity or alkalinity, which is measured as pH. The pH reflects the hydrogen concentration of the solution.

The higher the hydrogen ion concentration, the lower the pH (more acidic) and vice versa. Body fluids are main tained within a narrow range that is slightly alkaline (arterial blood is between 7.35 and 7.45).

Several body systems, including buffers, the respiratory system, and the renal system, are actively involved in maintaining the narrow pH range necessary for optimal function. The lungs and kidneys help maintain a normal pH by either excreting or retaining acids and bases.

Buffers (substance that keeps a constant balance between acid and alkali) prevent excessive changes in the pH by removing or releasing hydrogen ions. The major buffer system in ECF is the bicarbonate (HCO3) and carboni c acid (H2CO3) system.

The amounts of bicarbonate and carbonic acid in the body vary. However, as long as a ratio of 20 parts of bicar bonate to 1 part of carbonic acid is maintained, pH remains within normal limits. In addition, plasma proteins, hemoglobin, and phosphates function as buffers.

Regulation of Acid-Base Balance Low pH = acidic High pH = alkalinic Body fluids maintained between pH of 7.35 and 7.45 by o Buffers o Respiratory system o Renal system

Buffers

Prevent excessive changes in pH Major buffer in ECF is HCO3 and H2CO3 Other buffers include: o Plasma proteins o Hemoglobin o Phosphates

The lungs help regulate acid base balance by eliminating or retaining carbon dioxide, a potential acid. Combined with water, carbon dioxide forms carbonic acid. This chemical reaction is reversible.

Working together with the bicarbonatecarbonic acid buffer system, the lungs regulate acid base balance and pH by altering the rate and depth of respirations.

Carbon dioxide is a powerful stimulator of the respiratory center. When blood levels of carbonic acid and carb on dioxide rise, the respiratory center is stimulated and the rate and depth of respiration increase. Carbon dioxi de is exhaled and carbonic acid levels fall.

By contrast when bicarbonate levels are excessive, the rate and depth of respirations are reduced, causing car bon dioxide to be retained, carbonic acid to rise, and excess bicarbonate to be neutralized.

The respiratory system response to changes in pH is rapid, occurring within minutes.

The kidneys are the ultimate long-term regulator of acid base balance. They are slower to respond to changes, requiring hours to days to correct imbalances, but their r esponse is more permanent and selective than that of the other systems.

Kidneys maintain acid base balance by selectively excreting or conserving bicarbonate and hydrogen ions. When excess hydrogen ion i s present and the pH falls (acidosis), the kidneys reabsorb and regenerate bicarbonate and excrete hydrogen io ns

In the case of alkalosis and a high pH, excess bicarbonate is excreted and a hydrogen ion is retained.

Factors Affecting Body Fluid, Electrolyte, and Acid-Base Balance Age Gender Body size Environmental temperature Lifestyle

Age infants and growing children have much greater fluid turnover than adults because of their higher metabolic ra tes, increase fluid loss, immature kidneys (infants), rapid respiratory rate (infants), and greater body surface ar ea (infants).

In elderly people normal aging process and the likelihood of the presence of chronic diseases may affect fluid b alance. Thirst is blunted (not sharp); nephrons are less able to conserve water in response to ADH.

Gender and body size fat cells contain little water and lean tissue has an increased water content. People with a greater percentage o f body fat have less body fluid. Women have proportionally greater body fat than men and have less body wat er than men.

Environmental temperature individuals with illness and participation in strenuous exercise are at risk for fluid and electrolyte imbalances w hen the environmental temperature in high the loss of water and salt in sweat.

Lifestyle diet (intake of fluid and electrolytes), exercise (calcium balance), and stress (increases cellular metabolism, blo od glucose concentration, and cathecholamine levels) affect fluid and electrolyte and acid base balance. Heavy alcohol consumption decreases calcium, magnesium, and phosphate levels and increases t he risk of acidosis from breakdown of fat.

Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances Chronic diseases Acute conditions Medications Treatments Extremes of age Inability to access food and fluids

Chronic diseases (e.g., lung disease, heart failure, Cushings or Addisons diseases, diabetes mellitus, and cancer), acute conditions (e.g., acute gastroenteritis, burns, crushing injuries, surgery, or fever), medications (e.g., diuretics, corticosteroids, and NSAIDs), treatments (e.g., chemotherapy, intravenous therapy or total peripheral nutrition, nasogastric suction, enteral feedings, mechanical ventilation) and other factors (such as the very young and the very old, inability to access food and fluids independently) .

Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic imbalances occur when water and elect rolytes are lost or gained in equal proportions so that the osmolality of body fluids remains constant. Osmolar i mbalances involve the loss of only water so that the osmolality of the serum is altered.

Fluid Imbalances Isotonic loss of water and electrolytes (fluid volume deficit) Isotonic gain of water and electrolytes (fluid volume excess) Hyperosmolar loss of only water (dehydration) Hypo-osmolar gain of only water (overhydration)

Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions so that the osmolality of body fluids remains constant.

Osmolar imbalances involve the loss of only water so that the osmolality of the serum is altered. Thus there are four categories of fluid imbalances: an isotonic loss of water and electrolytes (fluid volume deficit), an isotonic gain of water and electrolytes (fluid volume excess), a hyperosmolar loss of only water (dehydration), and a hypo-osmolar gain of only water (overhydration).

The risk for dehydration increases with older age due to decreased thirst sensation. Also at risk for dehydration are clients who are hyperventilating or have prolonged fever or are in diabetic ketoacidosis and those receivin g enteral feedings with insufficient water.

Common manifestations of dehydration include weight loss, decreased skin turgor and capillary refill, dry muc ous membranes, weak, rapid pulse, decreased blood pressure and orthostatic hypotension, increased specific g ravity of the urine, hematocrit and blood urea nitrogen.

Overhydration may occur if only water is replaced or from the syndrome of inappropriate antidiuretic hormon e (SIADH), which can result from some malignant tumors, AIDS, head injury, or administration of certain drugs s uch as barbiturates or anesthetics.

Common manifestations of overhydration include weight gain, full bounding pulse, tachycardia, elevated blood pressure, distended neck and peripheral veins, adventitious lung sounds, shortness of breath, and confusion.

Collecting Assessment Data o Nursing history o Physical assessment o Clinical measurement o Review of laboratory test results o Evaluation of edema

The nursing history includes current and past medical history, medications, and functional, developmental, and socioeconomic factors. Common risk factors for fluid and electrolyte imbalances

The nurse also needs to elicit data about the clients food and fluid intake, fluid output, and the presence of sig ns or symptoms suggestive of altered fluid and electrolyte balance. The Assessment Interview provides exampl es of questions to elicit information regarding fluid, electrolyte, and acidbase balance.

lists the focused physical assessment of fluid, electrolyte, or acid base imbalances, including assessment of the skin, mucous membranes, eyes, fontanels (infants), cardiovascula r system, respiratory system, neurologic and muscular status.

Clinical measurement includes daily weights, vital signs, and fluid intake and output.

Evaluation of Edema

NANDA Nursing Diagnoses Deficient Fluid Volume Excess Fluid Volume

Risk for Imbalanced Fluid Volume Risk for Deficient Fluid volume Impaired Gas Exchange

NANDA Nursing Diagnoses Fluid and Acid-base Imbalances as Etiology o Impaired Oral Mucous Membrane o Impaired Skin Integrity o Decreased Cardiac Output o Ineffective Tissue Perfusion o Activity Intolerance o Risk for Injury o Acute Confusion

Desired Outcomes Maintain or restore normal fluid balance Maintain or restore normal balance of electrolytes Maintain or restore pulmonary ventilation and oxygenation Prevent associated risks o Tissue breakdown, decreased cardiac output, confusion, other neurologic signs

Nursing Interventions Monitoring o Fluid intake and output o Cardiovascular and respiratory status o Results of laboratory tests Assessing o Clients weight o Location and extent of edema, if present o Skin turgor and skin status o Specific gravity of urine o Level of consciousness, and mental status

Nursing Interventions

Fluid intake modifications Dietary changes Parenteral fluid, electrolyte, and blood replacement Other appropriate measures such as: o Administering prescribed medications and oxygen o Providing skin care and oral hygiene o Positioning the client appropriately o Scheduling rest periods

Promoting Fluid and Electrolyte Balance Consume 6-8 glasses water daily Avoid foods with excess salt, sugar, caffeine Eat well-balanced diet Limit alcohol intake Increase fluid intake before, during, after strenuous exercise Replace lost electrolytes

Promoting Fluid and Electrolyte Balance Maintain normal body weight Learn about, monitor, manage side effects of medications Recognize risk factors Seek professional health care for notable signs of fluid imbalances

Teaching Client to Maintain Fluid and Electrolyte Balance Promoting fluid and electrolyte balance Monitoring fluid intake and output Maintaining food and fluid intake Safety Medications Measures specific to clients problems Referrals Community agencies and other sources of help Facilitating fluid intake

Practice Guidelines Facilitating Fluid Intake Explain reason for required intake and amount needed Establish 24 hour plan for ingesting fluids Set short term goals Identify fluids client likes and use those Help clients select foods that become liquid at room temperature Supply cups, glasses, straws Serve fluids at proper temperature Encourage participation in recording intake Be alert to cultural implications

Practice Guidelines Restricting Fluid Intake Explain reason and amount of restriction Help client establish ingestion schedule Identify preferences and obtain Set short term goals; place fluids in small containers Offer ice chips and mouth care Teach avoidance of ingesting chewy, salty, sweet foods or fluids Encourage participation in recording intake

Correcting Imbalances Oral replacement o If client is not vomiting o If client has not experienced excessive fluid loss o Has intact GI tract and gag and swallow reflexes

Correcting Imbalances Restricted fluids may be necessary for fluid retention o Vary from nothing by mouth to precise amount ordered o Dietary changes

Oral Supplements Potassium Calcium Multivitamins Sports drink

Evaluation Collect data as identified in the plan of care If desired outcomes are not achieved, explore the reasons before modifying the care plan

Analysis of ABGs
Developing an understanding of ABG results will help caregivers to respond appropriately to their patients physiologic needs. If you wish to learn how to interpret arterial blood gas results you will need to use a systematic approach that involves memorizing a few key numbers and concepts. These include: Normal pH: 7.35 to 7.45. Normal CO2 (carbon Dioxide level/PaCO2): 35-45. Normal HCO3 (bicarbonate level): 22-26. Normal O2 (oxygenation level/PaO2/SaO2): 80-100. Later on in the course you will also learn about matching the CO 2 or the HCO3 with the pH and determining the significance of the CO2 or the HCO3 going the opposite direction of the pH.

Memorizing Key Components

In order to interpret ABGs accurately, you must memorize a few key numbers using a systematic approach. Always begin by evaluating the pH.

Step One: The pH

The first step to interpret ABGs is to determine if the patient has a normal pH. The pH will provide you your first most valuable piece of information: does the patient have acidosis or alkalosis. Recall that a normal pH value is 7.35 to 7.45. Now memorize the following facts: When the patients pH is less than 7.35, the patient has some type of acidosis. When the patients pH is above 7.45, the patient has some type of alkalosis. Some essential information is still missing though. You cant address the imbalance because you dont know what type of acidosis or alkalosis the patient is experiencing.

Step Two: Evaluating CO2

The second step to interpret an ABG result is to look at the carbon dioxide level. The normal carbon dioxide level for most patients is 35 to 45 mm Hg. Note the similarity between normal carbon dioxide levels (35-45 mm Hg) and normal pH (7.35-7.45). This may help to trigger your memory. Also note that when you evaluate carbon dioxide values, you are effectively looking at lung function. You will need to memorize that: A carbon dioxide level greater than 45 indicates acidosis (there is too much CO 2 being retained). A carbon dioxide (CO2) value less than 35 indicates alkalosis (there is not enough CO2).

14

Time for a Quick Review

Quick review so far: A normal pH is 7.35-7.45. A pH less than 7.35 means some type of acidosis, a pH greater than 45 means some type of alkalosis. A normal CO2 is 35-45. A CO2 value less than 35 indicates a low level of CO2 and indicates a respiratory alkalosis. A level greater than 45 means too much CO2 and a respiratory acidosis. Quick Application: Your patient has a pH of 7.24. Follow step one (look at the pH). The patient has a pH less than 7.35 and therefore has some kind of acidosis. This patient also has a CO2 of 55. Follow step two (look at the CO2). The CO2 level is greater than 45. This level is too high and indicates a lot of CO2. A high level of CO2 indicates acidosis. From the information you have learned so far, this patient has respiratory acidosis.

Step Three: Evaluating HCO3

Now its time to examine the bicarbonate component of ABG analysis. The third step to interpret an ABG result is to examine the bicarbonate level. A normal bicarbonate (HCO3) level is 22-26. You will need to memorize that: An HCO3 level less than 22 indicates there is not enough HCO3. A low level of bicarbonate means acidosis. An HCO3 value higher than 26 indicates a high level of bicarbonate, too much HCO 3. This means alkalosis.

Step Four: Matching pH, HCO3 and CO2 Using ROME

After the previous examples, you may have started to notice that whenever the pH is high and the HCO3 is high, the patient has metabolic alkalosis. In other words, when the direction of movement of the pH matches the direction of movement of the HCO3 (The direction of movement (up or down) is the same), the disorder is metabolic in nature. Conversely, when the direction of movement of the pH is opposite to the direction of movement of CO2, the disorder will be respiratory in nature. 15 For example: Your patients ABG results are as follows: pH: 7.50 CO2: 44 HCO3: 30 Step 1: Look at the pH. The pH is too high. This indicates some type of alkalosis. Step 2: Look at CO2. This value is within normal limits. Step 3: Look at HCO3 and note that it is too high (too alkaline). Step 4: Since both the pH and the HCO3 match in the direction of their movement (both are elevated), this is metabolic condition. Since both pH and the HCO3 are high, this indicates an alkalosis. This disturbance is thus a metabolic alkalosis.

Using Acronyms
Some people use the acronym R.O.M.E. to assist them in memorizing this concept / relationship: R = Respiratory O = Opposite M = Metabolic E = Equal Where: R=O and M=E What does this mean? The CO2 is the respiratory (R) component of the ABG. If CO2 moves in the opposite (O) direction to

the pH (ie: pH falls and CO2 increases), then the disorder is respiratory in nature. If pH falls and CO2 increases, there is a respiratory acidosis. If pH rises and CO2 decreases, there is a respiratory alkalosis. Remember: R=O (Respiratory = Opposite direction of movement) Conversely, the HCO3 is the metabolic (M) component of the ABG. If the HCO3 moves in the same/equal (E) direction to the movement of the pH (ie: pH falls and HCO3 falls), then the disorder is metabolic in nature. If the pH is low and the HCO3 is low there is a metabolic acidosis. If the pH is high and the HCO3 is elevated, there is a metabolic alkalosis. Remember: M=E (Metabolic = Equal / same direction of movement) Look at the examples again and use the acronym to confirm the result. Remember ROME to help you determine what ABG results mean. 16 Here is another example: Your patients ABG results are as follows: pH: 7.30 CO2: 50 HCO3: 22 Look at the pH. The pH is too low. This indicates some type of acidosis. The CO 2 is high. The pH and the CO2 are opposite one another, this is respiratory acidosis. After the previous examples, you may have started to notice that whenever the pH is high and the HCO3 is high, the patient has metabolic alkalosis.

Step 5: Is the Oxygen Saturation Out of Range?

A normal PaO2 is 80 100 millimeters (mm) of mercury (Hg). As healthcare professionals, we are very familiar with oxygen therapy. In general, when a patients oxygen level is low, we anticipate the healthcare provider will order oxygen therapy. One exception to correcting low levels of oxygenation involves patients with COPD (chronic obstructive pulmonary disease). Recall that the COPD patients respiratory drive does not trigger from the amount of CO2 but rather low O2 levels. If the amount of oxygen is increased the respiratory drive decreases and the patient will not breathe. In addition, research indicates that high levels of oxygen can be detrimental as well. Applying information on oxygen: The O2 is 74. This level is ____ and indicates ________ (low, hypoxia) The O2 is 130. This level is ____ and indicates ________ (high, too much O 2 or hyperoxia) The O2 is 96. This level is ____ and indicates ________ (normal, normal O2) You have almost mastered the art of interpreting ABGs! Before moving on to learn how to determine if the body if trying to correct a pH imbalance (compensation), review the following quick tips and practice interpreting a few basic ABG results.

Quick Tips
Step 1: Always look at the pH first to determine if a patient is acidotic or alkalotic: pH: A normal pH is 7.35 7.45. If the pH is less than 7.35, the patient is acidotic. If the pH is greater than 7.35, the patient is alkalotic 17 Step 2: Evaluate PCO2: A normal PaCO2 is 35 45 mm Hg. If the CO2 is less than 35 then it is below normal. The CO2 is low. If the CO2 is greater than 35 then the CO2 is above normal. The CO2 is high. Step 3: Evaluate HCO3: A normal HCO3 is 22 26 If the HCO3 is less than 22 then it is below normal. The HCO3 is too low. If theHCO3 is greater than 26 then it is above normal. The HCO3 is too high. Step 4: Matching pH, HCO3 and CO2

Use the acronym ROME to determine the cause of the disturbance: If the disturbance is respiratory in nature, the movement of CO2 will be in the opposite direction to the movement of the pH (R=Respiratory and O=Opposite direction). If the disturbance is metabolic in nature, the movement of HCO3 will be in the same direction to the movement of the pH (M=Metabolic and E=Equal or same direction). Step 5: Examine O2: A normal PaO2 is 80 100mm Hg. If the O2 is less than 80 then it is below normal. The O2 is too low. If theO2 is greater than 100 then it is above normal. The O2 is too high.

Nursing 140 Final Study online at quizlet.com/_ 53i2q

1. 1st BM since surgery, hard/dry formed stool: 2. 5 year old son playing naked with another boy: 38 year old female, boyfriend wants to have sex after smoking marijuana, nurse says:

Constipation Get boys interested in another activity Marijuana enhances sexual functioning Both parents share lack of desire there is no problem Practice/Prostate exams Teach Kegal Exercises Tell me more It's normal to go 2x a week Assist patient to restroom every 2 hours

3.

4. 45 year old had no interest in sex, not in 16 years, nurse interprets: 5. 52 year old man for physical exam, teach patient about: 6. 62 year old female- laugh/cough/ leakage of urine, intervention of care plan: 7. 62 year old man, dosen't respond to sexual stimulation, nurse response: 8. 80 year old worried no BM every day, nurse should say: 9. 87 year old dehydration, incontinent urine, nursing action best for care:

10. 88 year old, distended bladder, hyperplasia, agitated, confusion, intervention used Put in catheter

1st: A 43 year old is diagnosed with type 2 diabetes mellitus after being admitted to the hospital with an infected foot wound. When applying principles of adult learning, which teaching strategy by the nurse is most likely to be effective: a) Discuss the importance of blood glucose control in maintenance of long term 11. health b) Demonstrate the correct method for cleaning and redressing the wound to the patient c) Assure the patient that the nurse is an expert on management of diabetes complications A 52 year old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about: 12. c) Normal decreases in testosterone level d) Annual prostate specific antigen testing (PSA) A 72 year old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in 13. determining whether the patient has an upper tract infection (UTI): c) Foul smelling urine d) Costovertebral tenderness A 76 year old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep granulation tissue. The nurse documents the wound as a: 14. a) Red wound b) Yellow wound c) Full thickness wound A 78 year old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of 15. care: c) Insert an indwelling catheter until the symptoms have resolved d) Assist the patient to the bathroom every 2 hours during the day

B) Demonstrate the correct method for cleaning and redressing the wound to the patient

D) Annual prostate specific antigen testing (PSA)

D) Costovertebral Tenderness

C) Full thickness wound

D) Assist the patient to the bathroom every 2 hours during the day

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? D) Do you have difficulty with 16. c) Have you had chest pain with or without activity daytime sleeping d) Do you have difficulty with daytime sleepiness A client has a serum sodium concentration of 160 mEq/L and exhibits generalized weakness and confusion. The nurse should plan to initiate: 17. a) Fluid restrictions c) Monitoring of urine specific gravity d) Seizure precautions

A) fluid restrictions

A) Debride the area with wet18. A client has an open wound that is yellow and black. Using the RYB color code, which to-dry dressing nursing intervention needs to occur first?

a) Debride the area with wet-to-dry dressing b) Apply topical antibiotic ointment A client has been having pain without any clear pathology for cause. The most appropriately written nursing diagnoses for this client would be which of the following: 19. a) Pain due to unknown factors b) Pain related to unknown etiology c) Pain caused by psychosomatic condition d) Pain manifested by client's report A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate 20. which of the behavior- specific conditions: a) Interpersonal influences b) Perceived benefits of action c) Situational influences

B) Pain related to unknown etiology

B) Perceived benefits of action

A client has just returned to his room after undergoing exploratory abdominal 21. surgery. The nurse notes watery red drainage on his dressing. The nurse will describe Sanguineous the drainage as: A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results would the nurse expect to find in this patient: B) pH 7.47, PaCO2 43, HCO3 22. a) pH 7.30, PaCO2 50, HCO3 27 28 b) pH 7.47, PaCO2 43, HCO3 28 c) pH 7.43, PaCO2 50, HCO3 28 A client is attending classes on building positive relationships with significant others as well as learning skills to be open minded and respectful to those whose opinions are different. This client is focusing on which component of wellness: 23. a) Physical b) Social c) Emotional d) Environment A client is exhibiting signs and symptoms of acute confusion/delirium. Which strategy should the nurse implement to promote a therapeutic environment: 24. c) keep the room organized and clean d) Use restraints for client safety A client is hospitialized with numerous acute health problems. According to Maslow's Basic needs model, which nursing diagnosis would take the highest 25. priority: a) Risk for injury related to unsteady gait b) Altered nutrition, less than body requirements related to inability to absorb nutrients

B) Social

C) Keep the room organized and clean

B) Altered nutrition, less than body requirements related to inability to absorb nutrients

c) Self-care deficit related to weakness and debilitation d) Powerlessness related to chronic disease state A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly: a) Constipation, due to tissue trauma, manifested by no bowel movements for two C) Ineffective breast feeding, 26. days related to lack of motivation, b) Risk for infection, because of new incision, related to episiotomy secondary to exhaustion c) Ineffective breast feeding, related to lack of motivation, secondary to exhaustion d) Altered urinary elimination, secondary to childbirth A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he dosen't move." Which nursing diagnosis should be a priority: 27. A) Deficient Knowledge (pain control measures) b) Ineffective Health Maintenance A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? 28. c) Discontinue taking the pills d) Continue taking pills and discuss tapering the dose with the primary care provider

A) Deficient Knowledge (pain control measures)

D) Continue taking the pills and discuss tapering the dose with the primary care provider

A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? a) Assign UAP the task of giving the client's bath B) Ask the client the usual way 29. b) ASk the client the usual way bathing occurs at home bathing occurs at home c) Skipping the patient's bath and documenting "refused" is not following at clientcentered approach d) Tell the client that a bath is needed and ignore the client's comment A client who describes his pain as 6 on a scale of 1 to 10 is classified as having which of the following: 30. c) Moderate to severe pain d) Very severe pain A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has the following diagnoses: anxiety related to unfamiliarity of disease process, manifested by restlessness tachycardia. The etiology of this diagnoses is which of the following: 31. a) Unfamiliarity of disease process b) Anxiety c) Restlessness d) Tachycardia A client with acute pancreatitus has an abnormally low serum calcium level. 32. During a bath the nurse cleans the client's face with a cloth, and the lips, nose, and side of the face. When documenting this information the nurse would state that the patient's facial twitching indicates the presence of:

C) Moderate to severe pain

A) Unfamiliarity of disease process

C) Chrostek's Sign

c) Chrostek's sign d) Bell's palsey A client with diabetes who needs to learn to inject his own insulin states, "Ive had a good night's sleep, so let's tackle that syringe." The client if showing: 33. a) Feedback c) Readiness A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply: a) Amount of sleep he usually obtains during the week and on weekends 34. b) How much alcohol he usually consumes c) Onset and duration of symptoms d) Whether or not his classes are boring e) What medications including herbal remedies, he is taking

c) Readiness

a) Amount of sleep he usually obtains during the week and on weekends c) Onset and duration of symptoms e) What medications, including herbal remedies, he is taking

A community health nurse is testing the theory of locus of control (LOC). Which of the following client's demonstrates the internal control concept of this theory: a) A client who takes an active role in all health decisions A) A client who takes an active 35. b) A client who allows the primary care provider to make all the decisions role in all health decisions c) A client who does not make any decisions without his/her souse's input d) A client who relies on information from the local hospital for his.her health needs 36. A home health nurse is working with a patient who quit his job after injury- life has no meaning and lonely- everyone has left him- what is this a sign of: Spiritual Distress

A nurse in instructing a hospitalized client with a diagnosis of emphysemia about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following position will the nurse instruct the 37. client to assume: c) Sitting in a recliner chair d) Sitting on the side of the bed and leaning on an over bed table A nurse is practicing the concept of holism to the client. Which of the following is the best example of this: a) The nurse considers how the loss of a client's job will affect the regulation of the client's diabetes 38. b) The nurse makes sure to do a complete teaching regarding pharmacological interventions c) The nurse is careful to follow physician treatments on schedule d) The nurse is able to prioritize the needs of the client assigned according to Maslow's hierarchy

D) Sitting on the side of the bed and leaning on an over bed table

A) The nurse consider's how the loss of a client's job will affect the regulation of the client's diabetes

A nurse is providing a back rub to a client just after administering a pain 39. medication, with the hope that these two actions will help decrease the client's C) Implementation pain. Which phase of the nursing process is this nurse implementing: a) Assessment

b) Diagnosis c) Implementation d) Evaluation A nursing activity that is carried out during the evaluation phase of the nursing process is: a) Determining if interventions have been effective in meeting patient's outcome A) Determining if interventions 40. b) Documenting the nursing care plan in the progress notes in the medical record have been effective in meeting c) Deciding whether the patient's health problems have been completely resolved patient's outcomes d) Asking the patient to evaluate whether the nursing care provided was satifactory A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nurse's professor responds: "The nursing diagnosis statement: 41. a) Describes client problems that nurses are licensed to treat c) Includes the disease the client has during the treatment of care d) Helps standardize care for all clients A patient complains of not having had a bowel movement since being admitted 2 days ago for multiple fractures of both lower legs. The patient is on bedrest and has skeletal traction. Which intervention would be the most appropriate nursing 42. action: a) Administer an enema c) Ensure maximum fluid intake (3000 mL/day) d) Perform range of motion exercises to all extremeties A patient complains of pain during circumfusion of the shoulder when the nurse moves the arm behind the patient which question should the nurse ask: 43. a) Do you have difficulty in putting on a jacket b) Are you able to feed yourself without difficulty A patient has the following arterial blood gas (ABG) results: ph 7.32, PAO2 88 mmHg, PaCO@ and HCO3 16 mEqL. The nurse interprets these results as: a) Metabolic acidosis 44. b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care: 45. a) Place a bedside commode near the patient's bed b) Demonstrate the use of the Crede maneuver to the patient A patient is receiving 3% NaCl solution for correction of hypoatremia. During administration of the solution, the most important assessment for the nurse is to 46. monitor is: a) Lung sounds c) Peripheral pulses

D) Helps standardized care for all clients

...

A) Do you have difficulty in putting on a jacket

A) Metabolic Acidosis

A) Place a bedside commode near the patient's bed

...

d) Peripheral edema A patient is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care: 47. a) Keep the patient positioned on the left side b) Obtain a daily x-ray to verify tube placement c) Check the gastric residual volume every 4 to 6 hours A patient is taking a potassium-wasting diurectic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as: a) personality change 48. b) Frequent loose stools c) Facial muscle spasms d) Generalized weakness A patient returns to the clinic with recurrent dysuria after being treated with trimethoprium and sulfamethoxazole (Bactrim) for 3 days. Which action will the 49. nurse plan to take: a) remind the patient about the need to drink 1000 mL of fluids daily b) Obtain a midstream urine specimen for culture and sensitivity testing

C) Check the gastric residual volume every 4 to 6 hours

D) Generalized weakness

B) Obtain a midstream urine specimen for culture and sensitivity testing

A patient returns to the surgical nursing unit following a vertical banded gastroplasty with a nasogastric tube to low, intermittent suction and a patient controlled analgesia (PCA) machine for pain control. Which nursing action should be included in D) Suport the surgical incision 50. the postoperative plan of care: during patient coughing and b) Offer sips of sweetened liquids at frequent intervals turning in bed c) remind the patient that PCA use may slow the return of bowel functions d) Support the surgical incision during patient coughing and turning in bed A patient substained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear and edematous. The nurse identifies the stage of healing of these wounds as long: 51. a) Inflammatory b) Proliferate d) Remodeling A patient who has a wound infection after major surgery has only been taking in about 50% to 75% of the ordered meals and states, "Nothing on the menu really appeals to me." Which action by the nurse will be most effective in improving the 52. patient's oral intake: a) Make a referral to the dietician d) Have family members bring in favorite foods from home

...

D) Have family members bring in favorite foods from home

A patient who has been admitted to the hospital for surgery tells the nurse, 'I do not feel right about leaving my children with my neighbor", which action should the D) Gather more data about the 53. nurse take next: patient's feeling about the a) Reassure the patient that these feelings are common for parents child-care arrangements b) Have the patient call the children to ensure that they are doing well c) Call the neighbor to determine whether adequate childcare is being provided

d) Gather more data about the patient's feeling about the child-care arrangements A patient who has just been started on continuous tube feedings of a full strength commercial formula at 100 mL/hr using a closed system method has six diarrhea stools the first day. What action should the nurse plan to take: 54. a) Slow the infusion rate of the tube feeding b) Check the gastric residual volumes more frequently c) Change the internal feeding system and formula every 8 hrs d) Discontinue administration of water through the feeding tube A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaCO@ 32 mmttg, and HCO 25 mEq/L. The nurse interprets these results as: 55. a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to: a) Obtain subjective data about the patient's family membrane 56. b) Omit subjective data collection and obtain the physical examination c) Use the health care provider's medical history to obtain subjective data d) Schedule several short sessions with the patient to gather subjective data A patient who is suspected of experiencing respiratory distress from a left-sided pneumothorax should be positioned: 57. a) On the right side b) In semi-fowler's position

A) Slow the infusion rate of the tube feeding

D) Respiratory Alkalosis

D) Schedule several short sessions with the patient to gather subjective data

B) In the Semi-Fowler's Position

A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnoses for this patient is: C) Impaired skin integrity a) Impaired physical mobility related to left-sided paralysis 58. related to altered circulation b) Risk for impaired tissue integrity related to left-sided weakness and pressure c) Impaired skin integrity related to altered circulation and pressure d) Ineffective tissue perfusion related to inability to move independently A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBC)s and a shift to the left. The nurse anticipates that the next action will be to: 59. a) Obtain wound cultures b) start antibiotic c) Reddress the wound with wet-to-dry dressing d) Continue to monitor the wound for purulent drainage A patient with frequent urinary tract infections ask the nurse how she can prevent 60. the reoccurence. The nurse should teach the client to: a) Douche after intercourse

A) Obtain wound cultures

B) Void every three hours

b) Void every three hours A patient with poor circulation to the feet requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? B) The patient will list three 61. a) The nurse will demonstrate the proper technique for trimming toenails ways to protect the feet from b) The patient will list three ways to protect the feet from injury by discharge injury by discharge d) The patient will understand the rationale for proper foot care after instructions A patient with protein calorie malnutrition who has had abdominal surgery is receiving potential nutrition (PN). Which assessment information obtained by the nurse is the best indicator that the patient is receiving adequate nutrition: 62. a) Blood glucose is 110 m/dL b) Serum albumin level is 3.5 mg/dL d) Surgical incision is healing normally

D) Surgical incision is healing normally

A student nurse who claims to be very uncreative and dose not understand why it is necessary to assess and develop new ideas in the clinical area. The best response by the nurse educator is: A) Creativity allows unique 63. a) Creativity allows unique solutions to unique problems solutions to unique problems b) Not all your answers are going to be from your textbook c) Creativity makes nursing fun d) You'll get bored if you don't learn to be creative 64. Actions by client effective in teaching: 65. Adult masturbating, nurse should: 66. Advantage of Ileal conduit: Clients walks alot Excuse me and leave the room > chance of ascending kidney infection

After completing a scheduled every 2-hour turn by turning the patient to the left side, the nurse notices a reddened are over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and 67. finds the redness has disappeared. How should the nurse document this area: a) Reactive hyperemia c) Stage II pressure ulcer d) Stage III pressure ulcer After the nurse implements diet instructions for a patient with heart disease the patient can explain the information but fails to make recommended dietary changes. The nurse's evaluations that: a) Learning did not occur because the patient's behavior did not change 68. b) Choosing not to follow the diet is the behaviors that resulted from learning c) The nursing responsibility for helping the patient make dietary changes has been fulfilled d) The teaching methods were ineffective in helping the patient learn the dietary information

A) Reactive Hyperemia

B) Choosing not to follow the diet is the behaviors that resulted from learning

69. All of the following nursing actions are included in the plan of care for the patient who is C) Offer the patient the malnourished. Which action is appropriate for the nurse to delegate to nursing assistive prescribed nutritional

personnel (NAP): c) Offer the patient the prescribed nutritional supplement between meals d) Assess the patient's strength while ambulating the patient in the room An 80 year old client is transferred to a long term care facility. On the second night, he becomes confused and agitated. What is the most appropriate nursing diagnosis? 70. c) Disturbed Sensory Perception d) Disturbed Thought Process An 85 year old client has impaired hearing. When creating the care plan which intervention should have the highest priority: 71. a) Obtaining an amplified telephone b) Teaching the importance of changing his position An example of correctly written nursing diagnoses statement is: a) Altered tissue perfussion related to heart failure 72. b) Risk for impaired tissue integrity related to sacrel redness c) Ineffective coping related to response to biopsy test results d) Altered urinary elimination related to urinary tract infection An older patient receiving intravenous fluids at 175 mL/HR is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as 73. being which complication of intravenous fluid therapy: b) Fluid volume excess c) Pulmonary embolism An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease (COPD) to deliver a precise oxygen concentration. Which of the following types 74. of oxygen delivery systems would the nurse anticipate to be prescribed: a) Face tent b) Venture Mask

supplement between meals

C) Disturbed Sensory Perception

A) Obtaining an amplified telephone

C) Ineffective coping related to response to biopsy test results

B) Fluid volume excess

B) Venture Mask

As a young adult single mother of a second-grade child has to make a decision regarding the teacher for her child will have in third grade and asks the nurse for advice: All other B) A man who is 40 years 75. variables being equal which choice is best: old a) A woman with 35 year old of teaching experience b) A man who is 40 years old 76. Assessing UTI labs, finding immediate intervention: 77. At risk for difficulty urination elimination: At SAM, a nurse checks the amount of solution left in a potential nutrition infusion bag for an assigned client. It is a 3000 mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The 78. nurse plans to change the infusion bag and tubing today at: a) Noon b) 2 pm Left shift of WBCs 80 year old male, frequent urination at night

A) Noon

At which age does a child begin to accept that he or she will someday die: 79. c) 9-12 years old d) 12-18 years old 80. Bactrum BID, E.Coli, UTI: Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for 81. the nursing care plan? By day 5, the client will: b) Report falling asleep within 20 to 30 minutes c) Have a plan to pay all bills 82. Bedpan verses on toilet: 83. Black: 84. Bladder Infection, most important to report to Dr: 85. Can you use essential oils for Asthma: True or False

c) 9-12 years old

Take antibiotic for full amount time, finish them all

B) Report falling asleep within 20 to 30 minutes

Sitting position increase pressure in abdomen Debride Flank pain True Transparent Female not taking estrogen therapy- females at greater risk Less bladder pain/burning Get culture Have them sign informed consent Call physician Prolonged use of laxatives a) Coping is a more immediate, short term response to stress Clear liquids with Gatorade

86. Characteristic normal urine:

87. client at greater risk for bladder infection:

88. Client statements indicates Pyridium is effective: 89. Clinic with recurrent dysuria, and taking Bactrum, nurse should: 90. Colonoscopy, nurse action: 91. Colostomy stoma, dark blue in color: 92. Contributes to constipation: Coping with stress differs from adaption to stress in that: 93. a) coping is a more immediate, short term response to stress b) Coping is a later response to stress 94. Diagnosis of diarrhea, day of admission, diet to be ordered: During a routine physical, an 11 year old tells the nurse that many students in school are "doing it". How should the nurse respond to this statement: 95. a) Tell the client to talk with parents about sexual matters b) ASk what "doing it" means to the client

B) ASk what "doing it" means to the client

A) Encourage the mother to 96. During a well-child visit, a mother tells the nurse that her 4- year old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not consider putting her daughter

take a napin the afternoon. Which is the best response by the nurse: a) encourage the mother to consider putting her daughter to bed between 8 and 9 pm d) Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse recognizes this description to be 97. characteristic of which type of pain: c) Visceral d) Neuropathic

to bed between 8 and 9 pm

D) Neuropathic

During an initial interview the client makes this statement, I'm really not that sick or in pain right now. The nurses best response is: a) It's ok to be worried surgery is a big step B) What kind of questions do 98. b) What kind of questions do you have about your surgery you have about your surgery c) I think these are things you should be asking your doctor d) have you had surgery before During the assessing component of the nursing process, the primary reason for interviewing the client is to: 99. D) Collect Data c) Provide emotional therapy d) Collect data During which stage of NREM sleep would you expect a client to be most difficult to arouse: 100. c) Stage III d) Stage IV Formulating nursing diagnoses and client strengths is a joint function of: 101. c) Nurse and client d) Physician and client 102. Healing Touch: 103. Home health nurse teacher patient about straight catheter, effective statement by patient:

d) Stage IV

C) Nurse and client

Realign energy flow Clean catheter before and after each use What constitutes, varies among religion B) Orthopneic position across the over bed table

104. Homosexual, worried about him, nurse should consider the factor of saying: How should the nurse position a client who is complaining of dyspnea: 105. a) A high fowler's position with two pillows behind the head b) Orthopneic position across the over bed table How should the nurse use the JCAHO 2006 National Patient Safety Goals to improve communication among caregivers: 106. a) Review a list of look-a-like sound-a-like drugs used in the organization c) Studying a list of abbreviations that are not to be used throughout the organization

C) Studying a list of abbreviations that are not to be used throughout the organization

d) Use the client's room number as an identifier Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient's coping-stress tolerance pattern is: 107. b) What do you think caused this abdominal pain c) How do you feel about yourself and your hospitalization d) Are there other major problems that are a concern right now In discussing diet modifications the nurse encourages a client with cellulitus and severe inflammation to include: 108. c) Pretzels d) Citrus fruit In planning preoperative teaching for a patient undergoing a Roux-en y gastric bypass as treatment for morbid obesity the nurse places the highest 109. priority on: b) Discussing the necessary postoperative modifications in lifestyle c) Teaching the patient proper coughing and deep breathing techniques 110. Incontinence, assess in client: 111. Indwelling catheter securing: 112. Low-residue diet to prevent constipation instruct client to: 113. Mild anxiety: 114. Most important for nurse, on sexual problems: 115. NAP taking action to get urinary specimen, action requires nurse intervene: 116. Normal Range for HCO3: 117. Normal Range for pH: 118. Normal Range for: PaCO2 119. Nuring Diagnosis appropriate for client with indwelling catheter, bag is on the floor:

D) Are there other major problems that are a concern right now

D) Citrus Fruit

C) Teaching the patient proper coughing and deep breathing techniques

laughing leakage Preventing trauma from external structures Increase fluid intake Perception and learning is enhanced Know how you feel first Disconnecting catheter drainage tube 21-28 mEq/L 7.35- 7.45 35-45 mm Hg Risk for Infection Decrease in force of urinary stream

120. Nurse ask when history of BPH: Nurses must use critical thinking in their day-to-day-practice, especially in circumstances surrounding client care and wise use of resources. In which of 121. the following situations would critical thinking be most beneficial: a) Administering IV push medications to critically ill patients b) Educating a home health patient about treatment options c) teaching a new parent car seat safety

B) Educating a home health patient about treatment options

d) Assisting an orthopedic client with the proper use of crutches Nurses often utilize systems theory to assess family units. Which example illustrates a family unit that does NOT meet the criteria of a well-functioning 122. system? c) Each member's personal boundaries are well defined d) The primary activities of each member focus on personal purposes 123. Nursing action most helpful decreasing risk of hospital acquired infections, in urinary tract:

D) The primary activities of each member focus pn personal purposes

Avoid unnecessary catheters Empty Bladder Completely

124. Nursing intervention, preventing UTI:

On one of the first days working alone, the novice nurse must provide teaching on tracheotomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to: A) ASk the nurse mentor to assist a) ASk the nurse mentor to assist with the teaching after reviewing the 125. with the teaching after reviewing procedure the procedure b) Read the policy and procedure manual before the teaching session c) Do the best the nurse can by remembering what was taught in nursing school d) ASk for a different assignment until the nurse feels comfortable with this one One of the client's assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not not listed in the drug reference manual. The best action of the nurse is to: a) Follow the physician's order as written and give the medication 126. b) Call the pharmacy and do further investigating before administering the medication c) Ask the client about this medication d) Call the physician and ask what the medication is and what it is used for Outcome statement is: a) Client will ambulate without a walker by 6 weeks 127. b) Client will ambulate freely in house c) Client will not fall 128. Outcome/ Goal, urinary pattern alteration related to enlarged prostate: 129. People in crisis - can they work through crisis if someone works with them 130. Plan of care, chronic constipation, which foods nurse should emphasize: 131. Post menopausal, infection, why is this happening now, nurse says: 132. Prevention of UTI when patient states: Prior to finalizing a family orientated nursing care plan and implementing interventions, it is essential for the nurse to perform which of the following: 133. a) Meet with all family members simultaneously c) establish a trusting relationship with the family as a group

B) Call the pharmacy and do further investigating before administering the medication

A) Client will ambulate without walker by 6 weeks

Avoid Bladder Distension Yes Greens Estrogen levels, more susceptible Empty bladder every 3/4 hrs. throughout day

C) establish a trusting relationship with the family as a group

134. Promotes normal defecation: 135. Purpose of a urinary catheter: 136. Purulent: 137. Pyridium: 138. Rectal surgery, aptient urinates 50 mL of urine, every 30-60 kin, nurse should: 139. Red: 140. Role Ambiguity: Don't know if I'm ready to be a mom: 141. Sanguineous: 142. Scan amount of urine 100-500 mL a day: Series of "small successes is positive way to help clients True or False

Privacy Amount of residual urine Pus Urine will turn florescent orange Perform a bladder scan Cover Negative self-esteem Red Oliguria > 500 mL, low urine output True Clear and blood tinged Clear Sexual history varies on case by case basis Conceiving isn't related to orgasm Limit total intake of fluids

143.

144. Serous Sanguineous: 145. Serous: 146. Sexual history on admission:

147. Stop intercourse before orgasm to not get pregnant; 148. Stress incontinence, nutrition therapy, need more teaching: The 45 year old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How does the nurse interpret this 149. assessment data: c) If both partners share the same lack of desire there is often not a problem d) This situation is so unnatural that some dysfunction is present The aspect of an older adult's history indicating a risk, for developing hyperatremia is that the client: 150. c) Takes an over the counter antacid d) Has had frequent urinary tract infections The client being admitted from the ED is diagnosed with a fecal impaction. Which nursing intervention should be implemented: 151. c) Administer an oil retention enema d) Prepare for an UGI X-ray 152. The client experienced female circumcision as a puberty ritual while living in Africa as a child. What condition should the nurse monitor the client as an adult:

C) If both partners share the same lack of desire there is often not a problem

C) Takes an over the counter antacid

C) Administer an oil retention enema

C) Chronic Urinary Tract Infection

c) Chronic urinary tract infection d) Tendency for postpartum hemorrhage The client has a documented Stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client: 153. C) Impaired Tissue Integrity c) Impaired tissue integrity d) Risk for Injury The client has been close to death for some time and the family asks how the nurse will know when the client has actually died,. Which of the following would be the C) When there is no apical 154. most accurate response from the nurse: pulse c) When there is no apical pulse d) When the extremities are cool and dark in color The client is admitted to a comprehensive rehabilitation center for continuing care,following a motor vehicle crash. While the admitting nurse will develop the initial care who will be involved with the ongoing planning of this client's care: 155. a) The admitting nurse continues to assume that responsibility b) All nurses who work with the client c) Everybody involved in the client's care d) The client and the client's support system The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse: 156. b) Palpate for bladder fullness c) Inspect the sacrel area for edema d) Use the PRN order to medicate the client with an antacid

C) Everybody involved in the client's care

C) Inspect the sacrel area for edema

The daughter of an 80 year old man is aphastoc after suffering a cerebrovascular accident (stroke) express concern that their father is "always" exposing and playing with B) Assess the client's himself and his catheter. While they are in the room. Upon assessment the nurse finds 157. penis for irritations from the patient pulling on and rubbing his penis. What is the nurse's priority action: the catheter b) Assess the client's penis for irritations from the catheter c) ASk the client to keep his linens at waist level when he has visions The edges of a patient's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to 158. be healing by: a) Primary intention b) Secondary intention The most appropriate manner in which to state an intervention directed towards assisting a client with ambulation is: 159. a) Assist patient with ambulation b) Ambulate with client, using gait belt, two times daily for 15 minutes The mother of a 1 month old infant is concerned because the infant has had vomiting 160. and diarrhea for 2 days. What instructions should the nurse give this infants mother: a) Have the infant be seen by a physician

A) Primary Intention

B) Ambulate with client, using gait belt, two times daily for 15 minutes A) Have the infant be seen by a physician

b) Give the infant at least 2 ounces of juice every 2 hours The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in the client's plan of care: 161. a) Weight-bearing activities to stimulate joint relaxation b) Range of motion exercises to prevent worsening of contractures c) Exercises to strengthen flexor muscles The nurse anticipates that osteoposis may result from prolonged immobilization because of: 162. a) Lack of weight bearing, which decreases osteoblastic activity b) Decreased dietary calcium intake The nurse assess a surgical patient in the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate: 163. a) Obtain wound cultures b) document the assessment d) Assess the wound every 2 hours The nurse assesses an open area over a patient's greater trochanted that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional findings 164. would indicate to the nurse that this is a Stage IV pressure ulcer: b) The crater extends into the subcutaneous tissue c) The joint capsule of the hip is visable B) Range of motion exercises to prevent worsening of contractures

A) Lack of weight bearing, which decreases osteoblastic activity

D) Assess the wound every 2 hours

C) The joint capsule of the hip is visable

The nurse case manager is concerned about A particular client being discharged from the hospital. Which of the following factors, if present for this client, would alert the nurse to possible problems with treatment adhearance: A) The prescribed 165. a) The prescribed therapy is costly and of unknown duration therapy is costly and of b) The therapy will require no lifestyle changes of the client unknown duration c) The client has not had difficulty understanding the regimen d) The client's culture is supportive of Western medicine The nurse has admitted a patient with a new diagnoses of pneumonia and explained to the patient that together they will plan the patient's care and set goals for discharge. The patient says, "How is that different from what the doctor does?" Which response by the nurse is most appropriate: 166. c) Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors d) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health The nurse has completed discharge teaching for a client who will be going 167. home on oxygen therapy. Which statement made by the client, would indicate that this client needs further instruction: a) I will replace my cotton blankets with polyester ones

D) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health

A) I will replace my cotton blankets with polyester ones

b) My son will not be able to smoke when I am around The nurse has formulated a diagnosis of Activity Intolerance related to Decreased Airway Capacity for chronic asthma. In looking at the client's coping skills, the nurse realizes that the patient has a vast knowledge about the disease and what exacerbates symptoms in particular situations. D) The nurse wont have to spend time The nurse will utilize this information because: 168. going over the pathology of the client's a) Strengths can be an aid to mobilizing health and the healing process disease c) It will be easier for the nurse to educate the client about other interventions d) The nurse wont have to spend time going over the pathology of the client's disease The nurse has just received change-of-shift report about the following four patients which patient will the nurse assess first: a) The patient who has multiple black wounds on the feet and ankles b) The newly admitted patient with a stage IV pressure ulcer on the D) The patient who has been receiving 169. coccyx immunosuppressants medications and c) The patient who needs to be medicated with multiple analgesics has a temp of 102' F before a scheduled dressing change d) The patient who has been receiving immunosuppressants medications and has a temp of 102' F The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client: 170. a) Institute an exercise plan that includes weight-bearing activities b) Protect the client's bones with strict bed rest d) Provide the client with assisted range of motion exercising twice daily

D) Provide the client with assisted range of motion exercising twice daily

The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge B) I don't have to have a bowel 171. teaching: movement every day a) In the future I will eat a banana every time I take the medication b) I don't have to have a bowel movement every day The nurse is caring for a patient diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first: C) Administer oxygen via 172. a) Take the client's vital signs nasal cannula b) Check the client's pulse oximetry c) Administer oxygen via nasal cannula The nurse is caring for an 80 year old female nursing home resident who has been admitted to the hospital with pneumonia and is becoming progressively more 173. confused. Her vital signs are: Temp 101' F, Pulse 112, Resp. 28 and BP 100/70. ABG results include pH 7.50, PaCO@ 25 mmHg, and bicarbonate level 18 mEq/L. The nurse interprets these findings to indicate: a) Respiratory acidosis secondary to hypoexmia

A) Respiratory acidosis secondary to hypoeximia

b) Respiratory acidosis secondary to anxiety The nurse is caring for an 80 year old patient with the medical diagnosis of heart failure. The patient has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client: 174. c) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea d) Excess fluid volume related to cognitive heart failure as evidence by edema and confusion The nurse is caring for the patient with clostridum difficile. Which intervention should the nurse implement to prevent nosocomial spread to other clients: 175. a) Wash hands with betadine for 2 min after giving care b) Wear nonsterile gloves when handling GI excretions

C) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea

B) Wear nonsterile gloves when handling GI excretions

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse's states, "This is not normal behavior". The nurse documents this is which of the following: 176. a) inference C) Objective data b) Subjective data c) Objective data d) Secondary subjective The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is: 177. a) Risk for deficient fluid volume related to excessive fluid loss from ostomy b) Disturbed body image related to presence of ostomy The nurse is developing a weight loss plan for a 21 year old patient who is morbidly obese. Which statement by the nurse is most likely to help the patient in loosing weight on the planned 1000 calorie diet: 178. c) Most of the weight that you lose during the first weeks of dieting is water weight rather than fat d) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise The nurse is doing bowel and bladder retraining for the client with oaraplegia. Which of the following is NOT a factor for the nurse to consider: 179. c) Fluid intake d) Sexual Function A) Risk for Deficient Fluid Volume related to Excessive Fluid loss from Ostomy

D) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise

D) Sexual Function

The nurse is organizing a wellness project to educate teenagers about keeping their B) The most important factors bodies healthy. Which information about diet and exercise should be included: 180. for maintaining health are diet a) Diet is the most important predictor of health and activity b) The most important factors for maintaining health are diet and activity The nurse is performing a dressing change for a client and notices that there is a 181. new area of skin breakdown near the site of the dressing. On closer examination, it a) Assessment appears to be caused from the tape used to secure the dressing. This would be an

example of which phase of the nursing process: a) Assessment b) Diagnoses c) Implementation d) Evaluation The nurse is performing an admission assessment on a 20 year old college student who is being admitted for electrolyte disorders of unknown etiology. Which 182. assessment is most important to report to the health care provider: c) The patient has history of weight fluctuations d) The patient's serum potassium level is 2.9 mEq/L

D) The patient's serum potassium level is 2.9 mEq/L

The nurse is preparing written handouts to be used as part of the standardized teaching plan for patient's who have been recently diagnosed with diabetes. Which of the following statements would be appropriate to include in the handouts: a) Polyphagia, polydipsia, and polyuria are common symptoms of Diabetes mellitus B) The use of the right foods b) The use of the right foods can help in keeping blood glucose at a near-normal 183. can help in keeping blood level glucose at a near-normal level c) Some diabetes control blood glucose with oral medications or nutritional interventions d) Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms The nurse is reviewing laboratory data for a patient who is receiving total parental nutrition. Which lab value should be immediately brought to the physicians attention: 184. a) BUN of 60 c) Serum glucose 328 d) Potassium of 3.5 The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on 185. the client's skin: b) Coat the patient's back and buttocks with baby powder after bathing c) Use a turn sheet lifted by two staff member to move the client in bed The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take: 186. a) Notify the patient's health care provider b) Give the prescribed PRN lorazepam (ativan) c) Start the prescribed PRN oxygen at 2 to 4 L/min The nurse notes that the tube fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What is the nurses priority action: 187. a) Place the client in high fowler's position b) Turn off tube feeding d) Assess the patient's bowel sounds

A) BUN of 60

C) Use a turn sheet lifted by two staff member to move the client in the bed

...

B) Turn off the tube feeding

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the D) Disconnecting the catheter 188. nurse intervene: from the drainage tube to c) Using an alcohol based hand cleaner before performing catheter care obtain a specimen d) Disconnecting the catheter from the drainage tube to obtain a specimen The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern: 189. a) The BP is 90/40 mm/Hg c) Oral fluid intake is 100 mL for the last 8 hours d) There is prolonged skin tenting over the sternum

A) The BP is 90/40 mm/Hg

The nurse obtains this information when assessing a 74 year old patient in the outpatient clinic. Which finding os of the highest priority when the C) History of recent loss of balance and 190. nurse is planning care for the patient: fall c) History of recent loss of balance and fall d) Complaint of left hip aching when jogging The nurse primarily uses the nursing process in the care of patient's: a) To explain nursing interventions to other health care professionals b) As a problem solving tool to identify and treat patient's health care problems 191. c) As a scientific based process of diagnosing the patient's health care problems d) To establish nursing theory that incorporates the biopsychosocial nature of humans The nurse receives change-of-shift report about the following four patients. Which patient will the nurse assess first: a) A patient who has malnutrition associated with 4+generalized pitting edema 192. b) A patient whose potential nutrition has 10 mL of solution left in the infusion bag d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs

B) As a problem solving tool to identify and treat patient's health care needs

d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs

The nurse teaching a 32 year old man with renal failure about the path physiologic mechanism of acid-base balance recognize that the instructions B) My breathing increases to correct 193. have been understood when the client says: imbalances a) I lose too much acid through my kidneys b) My breathing increases to correct imbalances The nurse uses the PLISSIT format in helping client's who have sexual dysfunction. Which action by the nurse best reflects the "P" section of this 194. format: a) ASk the physician for permission to discuss sexual topics with the client c) Acknowledge the clients spoken and unspoken sexual concerns when C) Acknowledge the clients spoken and unspoken sexual concerns when providing care

providing care The nursing action most appropriate for a client who has an infection and develops a fever of 99.8' F is to: 195. a) Continue to monitor the patient's temp b) Administer an antipyretic The nursing diagnosis Risk for Impaired Skin Integrity related to sensoryperception disturbance would best fit a client who: 196. a) Cut a foot by stepping on broken glass b) Uses a wheelchair due to paraplegia The nursing process is a dynamic process. This means that it: 197. a) Is ever changing to the client's needs b) Conveys the force or power of the health team

A) Continue to monitor the patient's temp

B) Uses a wheelchair due to paraplegia

A) Is ever changing in response to the client's needs

The patient has been admitted with complaints of shortness of breath for 2 week duration and has received the nursing diagnosis impaired gas exchange. Which admission laboratory result would support the choice of 198. A) Increased Hematocrit this diagnosis: a) Increased hematocrit b) Decreased BUN The patient has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the 199. client: c) Encourage the client to use a cathartic laxative on a daily basis d) Place the client on a high fiber diet The patient's teaching plan includes this goal, "The patient will select 2 gram sodium diet from the hospital menu for the next three days". Which evaluation method will be best for the nurse to use. When determining whether teaching was effective: a) Check the sodium content of the patient's menu choices over the 200. next three days c) Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites d) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented

D) Place the client on a high fiber diet

D) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented

The RN should incorporate which instructions into the teaching plan for a client with a urinary diversion: 201. b) Notify the physician if the stoma is deep pink and shiny ... c) Strands of blood appear in the urine d) Increase fluid intake The shift change while the nursing staff was waiting for the adult 202. children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following initial greetings is most A) I'm very sorry for your loss

appropriate: a) I'm very sorry for your loss b) I'll take you in to view the body To assess a patient's readiness to learn before planning, teaching activities, which question should the nurse ask: a) What kind of work and leisure activities do you do 203. b) What information do you think you need right now c) Do you have any religious beliefs that are inconsistent with the treatment To help alleviate spiritual distress effectively, the nurse must: 204. b) offer to pray with the client d) find out what the client perceives his/her spiritual needs to be To reduce shearing force for a bedridden client. It is most important for the nurse to: 205. A) Put bed in high Fowler's position b) Pull the client up in at least once an hour Two days after surgery for an Ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialists care for the stoma. The nurse identifies a 206. nursing diagnosis of: a) Anxiety related to effects of procedure on lifestyle b) Disturbed body image related to change in body function 207. Two days after surgery, patient wont participate with care and will only let ostomy nurse provide care:

B) What information do you think you need right now

d) find out what the client perceives his/her spiritual needs to be

a) Put bed in high Fowler's position

B) Disturbed body image related to change in body function

Disturbed Body Image

Upon assessment the nurse notes that the client is dyspneic; has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details: 208. C) Ineffective Airway Clearance b) Anxiety c) Ineffective airway clearance d) Impaired gas exchange Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of B) Determining the nurse's needs 209. which of the following: for assistance B) Determining the nurse's needs for assistance c) Supervision delegated care d) Reassuring the client 210. Urine output: 211. usually uses fleet enema, response by nurse: Alert physician if below 30 mL/hr Are you taking any Vitamin supplements

Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation: C) How has the pain impacted your 212. a) Is your pain worse at night life b) What brought you to the clinic c) How has the pain impacted your life d) You're feeling down about having pain, aren't you What is primary function of a family? 213. a) Provide everything each member wants b) Provide an environment that supports growth of individuals What is wrong with the following outcome? Client will be able to climb one flight of stairs without shortness of breath: 214. a) Nothing is wrong b) No target time is given When admitting a patient who has just Arrived on the medical unit with severe abdominal pain, what should the nurse do first: A) Complete only basic demographics data before addressing the patient's abdominal pain b) Medicate the patient for the abdominal pain before attending to the 215. health history and examination c) Inform the patient that the abdominal pain will be treated as soon as the health history is completed d) Take the initial vital signs and then deal with the abdominal pain before completing the health history When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the 216. following is the most appropriate response: a) Tell me what it means to you to have surgery b) you must be very glad to be having this lesion removed When assessing a 64 year old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan 217. to teach the patient about: c) Magnetic reasonable imaging (MRI) d) Dual energy x-ray absorption (OEXA) When assessing the musculoskeletal system the nurse's initial action will usually be to: 218. b) Have the patient move the extremities against resistance c) Observe the patient's body build and muscle configuration When assessing the patient who has a lower urinary infections (UTI), the 219. nurse will initially ask about: c) Poor urine output B) Provide an environment that supports growth of individuals

B) No target time is given

D) Take the initial vital signs and then deal with the abdominal pain before completing the health history

A) Tell me what it means to you to have surgery

D) Dual Energy X-ray Absorption (OXEA)

C) Observe the patient's body build and muscle configuration

D) Pain with urination

d) Pain with urination When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes the part of the purpose of the nursing process is to: 220. a) Deliver care to a client in an organized way b) Implement a plan that is close to the medical model c) Identify client needs and deliver care to meet those needs d) Make sure that standardized care is available to clients

C) Identify client needs and deliver care to meet those needs

When preparing to teach an 82 year old Hispanic patient who lives with an adult daughter ways to improve nutrition, which action should the nurse take first: B) Determine who shops for 221. a) Ask the daughter about the patient's food preference groceries and prepare meals b) Determine who shops for groceries and prepare meals When providing care using evidence-based practice, the nurses uses: a) Clinical judgement based on experience 222. c) Evidence-based guidelines in addition to clinical expertise d) Evaluation of data showing that the patient outcomes are met When reviewing both the client's problem list against the various identified nursing diagnoses, both of which include client and family input, the nurse is utilizing of the following processes to minimize diagnostic error: 223. a) Understanding what is normal vs. what is not normal b) Verifying c) Consulting resources d) Basing diagnoses on patterns When the body is subjected to invasion or trauma, the role of Europhiles is to: b) Release histamine into the circulation 224. c) Produce specific antigens d) Phagocytize injurious agents When the client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? 225. a) pain tolerance b) Pain intensity When the nurse assesses dyspnea in a client with congestive heart failure, she assesses for other manifestations of fluid volume excess including: 226. b) Peripheral Edema c) Increased hematocrit level d) decreased urine output When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate 227. assessment to include is: a) Skin turgor b) Daily weight D) Evaluation of data showing that the patient outcomes are met

B) Verifying

...

B) Pain Intensity

...

B) Daily Weight

c) Presence of edema When the nurse is planning for the physical examination of an alert 86 year old patient. Adaptions to the examination technique should include: a) Speaking slowly when directing the patient 228. b) Avoiding the use of touch as much as possible c) Using slightly more pressure for palpation of the liver d) Organizing the sequence to minimize position changes Which action can the nurse delegate to nursing assistive personnel (NAP) who help with treatment of a patient admitted with tuberculosis and placed on airborne precautions: a) Teach the patient about how to use tissues to dispose of respiratory secretions 229. b) Stock the patients room with all necessary personal protective equipment c) Interview the patient to obtain the names of family members and close contacts d) tell the patient's family members the reason for the use of airborne precautions Which are the following are normal physiological changes that occur during non- REM sleep: 230. b) Decrease in pulse d) drop in basal metabolic rate Which behavior is characteristic of someone who is coping well with stress: 231. c) Sets aside 30 min a day to exercise d) has no hobbies Which client is at greatest risk for experiencing sensory overload: 232. c) A 16 year old listening to loud music d) An 80 year old client admitted for emergency surgery Which factor reduces the risk of electrical hazards: 233. a) two-pronged electrical plugs b) Three-prolonged electrical plugs

D) Organizing the sequence to minimize position changes

B) Stock the patient's room with all the necessary personal protective equipment

B) Decrease in pulse

C) Sets aside 30 min a day to exercise

D) An 80 year old client admitted for emergency surgery

B) Three-prolonged electrical plugs

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care 234. provider: C) Left-Sided Flank Pain c) Left-sided flank pain d) Temp 100.1" F Which information obtained during the nurse assessment of the patient's nutritional- metabolic pattern may indicate the risk for 235. musculoskeletal problems: c) The patient is 5 ft. 2 inches and weighs 180 lbs. d) The patient prefers whole milk to nonfat milk

C) The patient is 5 ft. 2 inches and weighs 180 lbs.

Which nursing action will be included when the nurse is doing a wet-todry dressing change for a patient's Stage III sacrel pressure ulcer: a) Administer the ordered PRN oral opoid 30 min before the dressing A) Administer the ordered PRN oral opiod 236. change 30 min before the dressing change b) Soak the old dressing with sterile saline a few minutes before removing them Which nursing diagnoses would the nurse use for a client prone to falls: a) Deficient knowledge 237. b) Risk for Injury c) Risk for disuse syndrome d) Risk for suffocation Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity impairment related to immobility: 238. a) Encourage client to eat at least 40% of meals b) Restrict fluid intake c) Keep lines dry and wrinkle free Which nursing intervention would be the most beneficial in preparing the patient psychologically for ileostomy surgery: 239. a) Include the patient's family in preoperative teaching sessions b) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy Which of the following are considered defense mechanisms: 240. b) denial c) Sublimation

B) Risk for Injury

C) Keep linens dry and wrinkle free

B) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy

d) denial

Which of the following nursing diagnosis pertains to a client's learning needs: B) Altered health maintenance related to 241. b) Altered health maintenance related to knowledge deficit: catheter knowledge deficit: catheter care care d) Anxiety related to wife's illness Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a percutaneous endoscopic gastrostomy )PEG) tube may be delegated 242. to an LPN/LVN: a) Providing skin care to the area around the tube site b) Assessing the patient's nutritional status at least weekly

A) Providing skin care to the area around the tube site

Which of these patients in the clinic will the nurse plan to teach about risks associated with obesity: A) Patient who has a BMI of 18 243. a) Patient who has a BMI of 18 kg/m2 kg/m2 b) Patient with a waist circumference 34 inches (86 cm) d) patient whose waist measures 30 in. (75 cm) and hips measure 34 in. *85

cm) Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD: 244. a) The patient demonstrates the correct way to pursed lip breathe b) The client lists three signs/symptoms to report to the Health Care provider Which potential potassium order is safe for the nurse to implement: a) Add 20 mEq of KCL to 1,000 mL of IV fluid 245. b) 10 mEq KCL IV over 1-2 min d) 10 mEq KCL SQ Which problem is most appropriate for the nurse to identify for the client with diarrhea: 246. a) Alteration in skin integrity b) Chronic pain perception d) INeffective coping Which question should the nurse ask when assessing a patient who has a history of benign prostatic hyperplasia (BPH): 247. c) Has there been a decrease in the force of your urinary stream d) Have you been experiencing any difficulty in achieving an erection Which statement best reflects the nurse's assessment of the fifth vital sign: 248. a) Do you have any complaints b) Are you experiencing any discomfort right now Which statement indicates the client needs a sensory aid in the home: 249. a) I tripped over that throw rug again b) I can't hear the doorbell Which statement made by a post menopausal client, would the nurse evaluate as indicating the need for further assessment: 250. a) For some reason, I have more sexual desire than ever c) I am so glad that I don't need to worry about sex anymore d) Sex certainly takes longer that it used to, but im getting used to that Which would be an expected outcome for a client with the following nursing diagnoses self-care deficit related to congnitive impairment: a) The client will be able to name the staff that works on the day shift 251. b) The client will eliminate safety hazards in her environment c) The nurse will stress the importance of adequate fluid intake d) The client with supervision will brush her teeth While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in 252. determining: a) The degree of patient motivation and readiness to learn b) What information the patient will be able to understand

A) The patient demonstrates the correct way to pursed lip breathe

...

...

C) Has there been a decrease in the force of your urinary stream

B) Are you experiencing any discomfort right now

B) I can't hear the doorbell

C) I am so glad that I don't need to worry about sex anymore

D) The client with supervision will brush her teeth

D) Which instructional strategies should be used in teaching

c) That the family must be included in the teaching process d) Which instructional strategies should be used in teaching