ATI HESI Practice Fall 2019 Detailed Answer Key

1. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? A. Initiate a low-residue diet. Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate the provider will prescribe withholding of foods and fluids. This serves to manage the client's pain by limiting gastrointestinal activity and stimulation of the pancreas. B. Pantoprazole 80 mg IV bolus twice daily Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions. C. Ambulate twice daily. Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes. D. Pancrelipase 500 units/kg PO three times daily with meals Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute pancreatitis. 2. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. B. A room with another nonsurgical client Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A client who has tuberculosis should have a private room. C. A room in the ICU Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill. D. A room that is within view of the nurses' station Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be close to the nurses' station. 3. A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse Page 2 identify as an associated risk factor? A. Hypocalcemia Rationale: Hypercalcemia is a risk factor associated with urolithiasis. B. BMI less than 25 Rationale: Obesity, or having a BMI that is greater than 29, has been found to be a risk factor for the development of urolithiasis. C. Family history Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation. D. Diuretic use Rationale: Medications such as antacids, vitamin D, laxatives, and aspirin have been associated with the formation of urolithiasis. However, there is no indication that the use of diuretics place a client at an increased risk for stone formation. 4. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature Rationale: Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid.Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid.Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration.Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 5. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? A. Lower the height of the solution container. Rationale: Page 3 If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed. B. Encourage the client to bear down. Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema. C. Allow the client to expel some fluid before continuing. Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema. D. Stop the enema and document that the client did not tolerate the procedure. Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease the cramping. 6. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Page 4 Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 7. A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg Rationale: The nurse should identify this finding as within the expected reference range. B. Straw-colored urine from an indwelling urinary catheter Rationale: Straw-colored urine is an expected finding. More information is needed to determine whether to take action in this case. C. Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately. D. Respiratory rate 18/min Rationale: The nurse should identify this finding as within the expected reference range. 8. A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. B. anti-inflammatory Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. C. antiplatelet aggregate Rationale: Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart. D. antipyretic Rationale: Although aspirin does have an antipyretic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. 9. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the Page 5 emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin Rationale: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 3 hr and is not appropriate for emergency treatment of ketoacidosis. B. Insulin glargine Rationale: Insulin glargine is a long-acting insulin, with an onset of 2 to 4 hr. It is not appropriate for emergency treatment of ketoacidosis. C. Insulin detemir Rationale: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 hr and is not appropriate for emergency treatment of ketoacidosis. D. Regular insulin Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis. 10. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere. B. Inability to recognize his family members Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere. C. Right hemiparesis Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere. D. Aphasia Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere. 11. A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions Page 6 should the nurse take first? A. Stop the infusion of blood. Rationale: This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood. B. Inform the provider. Rationale: The nurse should inform the provider so that the provider can give prescriptions for monitoring and medication if needed. However, there is another action the nurse should take first. C. Obtain a urine specimen. Rationale: The nurse should obtain a urine specimen to check for hemolysis; however, there is another action the nurse should take first. D. Notify the laboratory. Rationale: The nurse should notify the blood bank so personnel can assist with checking for errors with the blood component product; however, there is another action the nurse should take first. 12. A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. "These tests help determine the degree of damage to the heart tissues." Rationale: Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels. B. "Cardiac enzymes will identify the location of the MI." Rationale: The nurse should inform the partner and the client of the protocols and prescriptions for the client who has an MI to decrease anxiety. The nurse should include that the 12-lead electrocardiogram may be used to determine the location of the MI in the teaching. C. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." Rationale: An echocardiogram is a diagnostic tool used to determine the heart structure and mobility of the heart valves. It can be used to diagnose cardiomyopathy, valvular disorders, aneurysms and left ventricular function. D. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." Rationale: Pulmonary congestion, a complication of MI, is suspected when crackles or rales are auscultated in the chest. Should this occur, the nurse should inform the client and partner that it is diagnosed by chest x-ray. Page 7 13. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. Rationale: The nurse should avoid routine catheter changes. The catheter should be changed only to correct a problem, such as a leakage or a blockage. B. Check the catheter tubing for kinks or twisting. Rationale: The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder. C. Irrigate the catheter once each shift. Rationale: The nurse should avoid irrigation of the catheter unless there is an obstruction. D. Clean the perineal area with an antiseptic solution daily. Rationale: The nurse should clean the perineal area with soap and water at least twice per day. 14. A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? A. History of smoking Rationale: Smoking is a modifiable risk factor, because the client has an ability to change via cessation. B. Obesity Rationale: Obesity is a modifiable risk factor, because the client should have the ability to change via diet. C. History of hypertension Rationale: Hypertension is a modifiable risk factor, because the client should have the ability to change via medication, exercise, and diet. D. Race Rationale: Race is a nonmodifiable risk factor, which the client is unable to control. 15. A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? A. Medications will need to be taken for the rest of the client's life, even if the client feels better. Rationale: Active TB is usually treated with the simultaneous administration of a combination of medications until the disease is controlled, usually 6 to 9 months but possibly as long as 2 years. Page 8 B. Medications will need to be taken until the Mantoux test is negative. Rationale: Once the client is diagnosed with active TB, the Mantoux test will remain positive for the remainder of the client's life. C. A typical course of treatment involves 6 to 9 months of consistent medication use. Rationale: Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time. D. The client's family will also need to take medications to prevent infection. Rationale: A client is treated with antitubercular medications only if she tests positive. Because of the serious side effects associated with TB medications and the prevalence of multidrug resistant TB, medications are not given to clients who are merely at risk for developing the disease. 16. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible Rationale: Although a semi-Fowler's position can help the client breathe more easily, it will not alter the consistency of secretions. B. Administering oxygen via nasal cannula at 2 L/min Rationale: Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of secretions. C. Helping the client select a low-salt diet Rationale: Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of secretions. D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration. 17. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.) A. Polyuria B. Blurred vision Page 9 C. Polydipsia D. Tachycardia F. Moist, clammy skin Rationale: Polyuria is incorrect. Manifestations of hyperglycemia include polyuria (excessive urination).Blurred vision is correct. Manifestations of hypoglycemia include blurred vision.Polydipsia is incorrect. Manifestations of hyperglycemia include polydipsia (excessive thirst).Tachycardia is correct. Manifestations of hypoglycemia include tachycardia.Moist, clammy skin is correct. Manifestations of hypoglycemia include moist, clammy skin. 18. A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. Remain on bedrest for the first 24 hr. Rationale: When the client has recovered from sedation, the client will be allowed to walk, as tolerated, but should be instructed not to overuse or strain the joint for a few days. B. Keep the leg in a dependent position. Rationale: Elevating the affected area in the postoperative period (12 – 24 hr) reduces pain and swelling. C. Apply ice to the affected area. Rationale: Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling. D. Begin active range of motion. Rationale: Although the client will be allowed to walk as tolerated, joint use should be minimized for the first few days to reduce postoperative pain and swelling. 19. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. B. Elevated ST segment Rationale: The nurse should identify ST depression as an indication of hypokalemia. C. Wide QRS Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia. Page 10 D. Inverted P wave Rationale: Inverted P waves are associated with junctional rhythms. 20. While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion Rationale: When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers. B. Alteration in body image Rationale: The nurse should address the client's alteration in body image because the client can consider the appearance of varicose veins, edema, and the ulcerations unattractive. However, another diagnosis is the priority. C. Alteration in activity tolerance Rationale: The nurse should assess the client for decreased ability to tolerate activity because the presence of varicose veins and edema can be painful and present a feeling of fullness in the legs. However, another diagnosis is the priority. D. Impaired skin integrity Rationale: The nurse should address the presence of venous stasis ulcers and edema because these factors can lead to infection, increased tissue breakdown, and delayed healing. However, another diagnosis is the priority. 21. A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? A. Montgomery straps Rationale: Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips. B. Enzymes Rationale: The nurse should use enzymes to debride a wound that contains eschar. C. Alcohol swabs Rationale: Page 11 The nurse should recognize that alcohol has a drying effect on the skin. D. A transparent dressing Rationale: The nurse should use a transparent dressing to protect a client from shearing forces. The transparent dressing should be used on intact skin. This type of dressing would cause damage each time it is removed, as the entire surface contains adhesive. 22. A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? A. To prevent fluid from accumulating in the wound Rationale: The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures. B. To limit the amount of bleeding from the surgical site Rationale: A JP drain does not limit the amount of bleeding. C. To provide a means for medication administration Rationale: A JP drain does not provide a means for medication administration. D. To eliminate the need for wound irrigations Rationale: A JP drain is not used as a substitute for wound irrigation. 23. A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? A. "An MRI scan is not distorted by movement, so you do not have to lie still." Rationale: An MRI scan is distorted by movement. It is important that the client is informed of the need to lie still during the procedure. B. "An MRI scan is a short procedure and should take no longer than 30 minutes." Rationale: An MRI scan is a lengthy procedure that lasts between 60 and 90 min. C. "The MRI contrast dye contains iodine and can cause your skin to itch." Rationale: MRI contrast dye does not contain iodine and therefore is not subject to hypersensitivity reactions like contrast dye used in a traditional CT scan. D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." Rationale: The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are Page 12 offered to reduce the discomfort. 24. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? A. Review the client's electrolyte values. Rationale: The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea. B. Check the client's perianal skin integrity. Rationale: The nurse should check the client's perianal skin integrity to identify areas of breakdown or excoriation; however, the nurse should take a different action first. C. Investigate the client's emotional concerns. Rationale: The nurse should investigate the client's emotional concerns to assist the client with the psychosocial coping of her condition; however, the nurse should take a different action first. D. Obtain a dietary history from the client. Rationale: The nurse should obtain a dietary history from the client to identify triggers for inflammation of the colon; however, the nurse should take a different action first. 25. A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? A. Notify the provider. Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if the output is bright rad and thick; however, the nurse should attempt a different intervention first. B. Check the tubing for kinks. Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen. C. Adjust the rate of the bladder irrigant. Rationale: The nurse may need to increase the rate of bladder irrigant to stimulate removal of urine and clots; however, the nurse should use a less restrictive intervention first. D. Irrigate the catheter. Rationale: The nurse may need to irrigate the catheter to check for an internal obstruction; however, the Page 13 nurse should use a less restrictive intervention first. 26. A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet Rationale: Elevating the feet can help improve circulation by decreasing dependent pooling of the blood and promoting venous return to the heart. B. Massaging her legs Rationale: Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication. C. Flexing her ankles Rationale: Ankle- and calf-pumping exercises can help reduce the risk of VTE postoperatively. D. Ambulating soon after surgery Rationale: Early ambulation after surgery does not increase the risk of VTE, and might help reduce the client's fear of life-threatening complications. 27. A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) Rationale: S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle. B. A friction rub Rationale: A friction rub is a high-pitched, scratchy sound that is heard can be heard in both systole and diastole. C. The third heart sound (S3) Rationale: S3 occurs early in diastole during filling of the ventricles. D. A split second heart sound S2 Rationale: A split S2 heart sound results from an audible delay between the closing of the aortic and pulmonic valves. 28. A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following Page 14 instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. Rationale: The client should be instructed to sleep on the back or the unaffected side to lessen pressure on the affected eye. Sleeping on the abdomen is not recommended. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. C. Bend at the waist to pick objects up from the floor. Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure, such as bending at the waist. The client should bend at the knees to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids. Rationale: White, crusty drainage on the eye lid is an expected finding. The client should notify the surgeon if she has green or yellow drainage on the eyelids or eyelashes. 29. A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. B. Decreased level of serum lipids Rationale: An increase serum lipid level is an expected finding for FES, although the reason for this finding is unknown. C. Decreased erythrocyte sedimentation rate (ESR) Rationale: An increased ESR is an expected finding for FES, although the reason for this finding is unknown. D. Increased platelet count Rationale: A decreased platelet count is an expected finding for FES, although the reason for this finding is unknown. 30. A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." Rationale: Page 15 This response is an example of unwarranted or false reassurance. It does not encourage the client to explain his feelings. B. "Before the examination, your provider will give you a sedative that will make you sleepy." Rationale: This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. C. "I know you’re anxious, but this procedure is recommended for people your age." Rationale: This statement is true. Routine screening for polyps and colon cancer is recommended starting at age 50; however, the nurse is changing the subject and this does not encourage the client to explain his feelings. D. "After you have signed the consent form, we can talk more about this." Rationale: The nurse should ensure that the client understands and agrees to the procedure before the client signs the consent form. 31. A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.) A. Discontinue suction when assessing for peristalsis B. Irrigate the NG tube with 0.9% sodium chloride irrigation solution. C. Place sequential compression devices on the bilateral lower extremities. D. Reposition the client from side to side every 2 hr. E. Encourage the use of an incentive spirometer every 2 hr while the client is awake. Rationale: Discontinue suction when assessing for peristalsis is correct. The nurse should turn off suction while auscultating the abdomen to determine the return of peristalsis because the suction masks any present bowel sounds.Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. The client requires the NG tube for gastric decompression, so the nurse must make sure it remains patent. Irrigating the NG tube with normal saline irrigation solution every 4 hr will ensure patency.Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow for clients who have mobility limitations and help prevent venous thromboembolism in the lower extremities.Reposition the client from side to side every 2 hr is correct. The nurse should reposition the client from side to side at least every 2 hr but should also assist with early ambulation to improve ventilation and help mobilize secretions.Encourage the use of an incentive spirometer every 2 hr while the client is awake is incorrect. Use of the incentive spirometer helps prevent atelectasis. The client should use the device each hour while awake. 32. A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? Page 16 A. Sputum culture for acid-fast bacillus (AFB) Rationale: A sputum culture is used to confirm a diagnosis of tuberculosis, but it is not the first diagnostic test the provider will prescribe. B. Nucleic acid amplification test (NAAT) Rationale: The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum. C. CT scan Rationale: A CT scan aids in confirmation of a diagnosis of pulmonary tuberculosis, but it is not the first diagnostic test the provider will prescribe. D. Chest x-ray Rationale: A chest x-ray is used for diagnosis of active pulmonary tuberculosis as well as for the detection of old, healed lesions, but it is not the first diagnostic test the provider will prescribe. 33. A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy Rationale: A myringotomy is a procedure that takes about 15 min. An incision is made in the tympanic membrane to reduce pressure and promote fluid drainage. Clients who undergo this procedure are not at risk for deep-vein thrombosis. B. Laparoscopic appendectomy Rationale: Laparoscopic appendectomy is a low risk procedure. Clients who undergo this procedure are not at risk for deep-vein thrombosis. C. Hip arthroplasty Rationale: Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively. D. Cataract extraction Rationale: Clients who are postoperative following cataract extraction are at risk for a number of complications, including infection and damage to the eye due to increased intraocular pressure, but are not at risk for deep-vein thrombosis. 34. A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. Serosanguineous drainage Rationale: Page 17 Purulent drainage, not serosanguineous drainage, from the pin sites is an indication of infection. B. Mild erythema Rationale: Redness is an expected finding after pin insertion. Severe redness at the pin sites is an indication of infection. C. Warmth Rationale: Warmth is an expected finding after pin insertion. Coolness of the extremity, however, could indicate neurovascular compromise. D. Fever Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites. 35. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? A. Calcium Rationale: The nurse should expect a decreased calcium level in a client who has acute pancreatitis. B. RBC count Rationale: The nurse should expect an elevated WBC count in a client who has acute pancreatitis. C. Magnesium Rationale: The nurse should expect to a decreased magnesium level in a client who has acute pancreatitis. D. Amylase Rationale: Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days. 36. A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Febrile Rationale: A febrile transfusion reaction can occur in clients who have received multiple blood product transfusions. It is a response in which anti-white blood cell (WBC) antibodies react with the WBCs remaining in the blood product. This results in chills, fever, hypotension, tachycardia and tachypnea. Clients who have a history of multiple blood product transfusions may receive Page 18 B. Allergic leukocyte reduced blood or single-donor HLA matched platelets along with a WBC filter to prevent febrile reactions. Rationale: Allergic (anaphylactic) transfusion reactions occur most often in clients who have pre-existing allergies. It is thought to be the result of a reaction to the plasma protein contained in the blood product. Manifestations include urticaria, itching, and flushing. In extreme cases, bronchospasm and laryngeal edema, and shock may occur. Onset may occur as late as 24 hr following the transfusion. Clients who have a history of allergies may receive blood products in which the WBCs, plasma, and immunoglobulin A has been removed or the client may be pre-treated with antihistamines and corticosteroids. C. Acute pain Rationale: An acute pain transfusion reaction can occur during or following transfusion with blood products. It manifests as severe chest, joint, and back pain, along with hypertension and flushing of the face and neck. The client is often anxious. Acute pain transfusion reactions are treated symptomatically with medications for pain and rigors. D. Hemolytic Rationale: A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse. 37. A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen? A. "I will closely follow a high-purine diet." Rationale: A client who has gout, a painful and potentially disabling form of arthritis caused by an excess of uric acid in the body, should avoid foods high in purines, such as organ meats and shellfish. B. "I will limit my fluid intake to 1 liter per day." Rationale: A client who has gout, a painful and potentially disabling form of arthritis that is caused by an excess of uric acid in the body, should remain well hydrated. A fluid intake of a minimum 2,500 mL/day is recommended to minimize uric acid stones. C. "I will take one aspirin every day." Rationale: A client who has gout, a painful and potentially disabling form of arthritis caused by an excess of uric acid in the body, should not take aspirin. Aspirin and other salicylates, even in small doses, can inactivate drugs used to treat gout, can interfere with uric acid excretion, and may precipitate an acute onset. D. "I will limit my alcohol intake." Rationale: A client who has gout should limit alcohol consumption, which is known to cause a gouty attack by inhibiting excretion of uric acid and leading to its buildup. However, clients should be encouraged to increase their fluid intake to help prevent formation of urinary stones. Page 19 38. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain assessment should also be completed if the client has a change in condition, such as a new onset of chest pain, or following a procedure which can be uncomfortable for the client, such as x-rays which require the client to lay on a hard surface for extended periods of time. A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although vital signs can be used as a physiologic indicator, monitoring them is an objective method of evaluating pain and may not be a reliable means of assessing pain levels. Evidence-based practice indicates the nurse should use a different parameter first. B. behavioral indicators and effect Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although behavioral indicators can be used, the nurse should recognize that pain behaviors are unique to each patient. Evidence-based practice indicates the nurse should use a different parameter first. C. scheduled treatments and client illness Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although treating a client based upon the client’s condition or based upon the client’s scheduled, potentially painful procedure will yield effective results at assessing pain levels, evidence-based practice indicates the nurse should use a different parameter first. D. a self-report pain rating scale Rationale: Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client’s self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable. 39. A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance A. twice a day. Rationale: The client who has an ileal conduit has had the bladder removed. The kidneys drain urine constantly into the diversion and the ostomy bag. Emptying the appliance twice daily would result in separation of the pouch from the skin due to the weight of the appliance. B. daily at bedtime. Rationale: Page 20 Because the appliance collects the urine that is constantly flowing from the kidneys, it must be emptied more frequently than once a day to prevent separation of the appliance from the weight of the urine and to ensure the urine does not back up into the diversion. C. when the bag is 2/3 full. Rationale: An ileal conduit is used to divert urine outside of the body when the urinary bladder has been removed. The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously, and an appliance must be worn as a collecting device. The bag should be emptied when it becomes 2/3 full to prevent leakage, skin irritation, and infection. D. when the bag is full. Rationale: The appliance collects the urine that is constantly flowing from the kidneys and must be emptied before it becomes completely full to prevent separation of the appliance from the weight of the urine. 40. A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? A. The client complains of pain. Rationale: Clients in traction frequently complain of both pain and muscle spasm, and should be medicated appropriately. Pain is not considered an adequate justification for removal of the weights. B. The client develops a life-threatening situation. Rationale: Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation. C. The client needs to have an x-ray of the femur performed. Rationale: To obtain an x-ray, the portable machine is brought to the client's room. An x-ray is not considered an adequate justification for removal of the weights. D. The client has to be repositioned in the bed. Rationale: To be repositioned, the client is moved using the assistance of others, or the client may learn to use an overhead trapeze. Repositioning is not considered an adequate justification for removal of the weights. 41. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." Rationale: The client who has kidney stones should drink plenty of fluid to prevent the urine from becoming concentrated, which leads to stone formation. The nurse should instruct the client to drink fluids (primarily water) every 1-2 hr and drink enough to produce more than 2,000 mL of urine each day. Page 21 B. "The last time I voided it was painful and red-tinged." Rationale: Manifestations of kidney stones depends upon the location of the stone but generally include flank pain, hematuria, and pyuria. Nausea and vomiting may also occur. C. "My period ended 2 days ago." Rationale: While x-ray is used for the IVP, a menstrual cycle that ended just 2 days prior to admission would make it highly unlikely that the client could be pregnant, and no special precautions need to be taken due to x-ray exposure. D. "I don't eat shellfish because it gives me hives." Rationale: The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider. 42. While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. Rationale: The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line. B. Initiate a new IV line in the other extremity. Rationale: While the client will require insertion of a new IV site, this is not the first action the nurse should take. C. Apply a hot pack to the irritated site. Rationale: While it is appropriate to apply a hot pack to the irritated site, this is not the first action the nurse should take. D. Determine if the client needs to continue IV therapy. Rationale: Prior to reinsertion of the IV line, the nurse should clarify that the IV therapy needs to continue. 43. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L Page 22 A. Respiratory acidosis Rationale: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a CO2 level that is higher than the normal reference range (35 – 45 mm Hg). B. Metabolic acidosis Rationale: Metabolic acidosis occurs when there is an alteration in the level of hydrogen ions or a reduction in the amount of bicarbonate available. It can be the result of diabetic ketoacidosis, starvation, hypoxia, renal or liver failure, dehydration, or diarrhea. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a bicarbonate (HCO3) level that is lower than the normal reference range (21 – 28 mEq/mL). C. Metabolic alkalosis Rationale: Metabolic alkalosis occurs when there is an alteration in the level of HCO3 along with an increase in the pH of the blood. It can be the result when a client ingests too much antacid from blood transfusions or total parenteral nutrition. It can also occur if the client has prolonged vomiting or NG suction, takes thiazide diuretics, or has a metabolic disorder such as hypercortisolism or hyper aldosteronism. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and an HCO3 level that is higher than the normal reference range (35 – 45 mm Hg). D. Respiratory alkalosis Rationale: Respiratory alkalosis occurs when there is an excessive loss of CO2 through hyperventilation, mechanical ventilation, fever, overdose of salicylates, or lesions to the central nervous system. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and a CO2 level that is lower than the normal reference range (35 – 45 mm Hg). 44. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. Rationale: Most clients with a baseline normal fluid status can tolerate being NPO overnight without risk of fluid volume deficit. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. Rationale: The client who has heart failure has ventricular impairment which prevents adequate filling or emptying of blood, resulting in fluid overload or inadequate tissue perfusion. An elevated BNP level is indicative of increased blood volume, thus fluid volume excess. C. The client who has end-stage renal failure and is scheduled for dialysis today. Rationale: The client who has end-stage renal failure is unable to appropriately filter blood and excrete waste products, including fluid. This client is likely to have a fluid excess that is managed with Page 23 dialysis. D. The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit. 45. A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? A. Establish the ability to communicate effectively. Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. B. Compensate for loss of depth perception. Rationale: A client who has a right-sided lesion experiences a loss of depth perception, proprioception (recognition of body position), and spatial deficits. The client who has a left-sided lesion will have an inability to discriminate between words and letters leading to problems reading. C. Learn to control impulsive behavior. Rationale: A client with a right-side lesion is likely to be impulsive. Clients with left-side lesions are typically cautious. D. Improve left-side motor function. Rationale: A client with a left-side lesion will demonstrate hemiplegia of the right side due to the fact that the pyramidal pathway crosses over at the base of the brain. 46. A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. Rationale: This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). Rationale: This change in temperature is not significant, as both values are within the expected reference Page 24 range. A client who has a fat embolism may develop a high temperature, usually 39.5º C (103 Fº). C. Increased blood pressure from 112/68 to 120/72 mm Hg. Rationale: This change in blood pressure is not significant, as both values are within the expected reference range. D. Increased heart rate from 68 to 72/min. Rationale: This change in heart rate is not significant, as both values are within the expected reference range. 47. A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? A. Obtain the client's blood glucose every 12 hr. Rationale: TPN can increase the client's blood glucose. Therefore, the nurse should obtain the client's blood glucose every 4 hr. B. Change the IV tubing every 24 hr. Rationale: The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing. C. Change the IV site dressing every 4 days. Rationale: The nurse should change the client's IV site dressing every 48 to 72 hr, or per facility protocol, to reduce the risk of infection. D. Weigh the client every other day. Rationale: The nurse should weight the client daily to determine if the client is gaining or losing weight. 48. A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A. Chest x-ray Rationale: A chest x-ray may be helpful for detecting old or new lesions that are large enough to be visualized. However, the client who has an HIV infection may have a normal x-ray or show infiltrates which would be expected in the client who has pneumonia. B. Sputum culture for acid-fast bacillus Rationale: Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis. Page 25 C. Sputum smear Rationale: A sputum smear is able to detect the presence of mycobacterium, but it does not distinguish between mycobacterium tuberculosis and other strains of mycobacterium. D. Mantoux test Rationale: The Mantoux skin test is an effective screening tool, but it is unable to distinguish between an active case of TB and a client who has been, at some time in the past, exposed to TB. The results are also variable, depending upon the skill of the nurse administrating and reading the test. 49. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? A. Output of burgundy colored urine Rationale: Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter. B. Pulse rate of 88/min Rationale: A pulse rate of 88/min is within the expected range for an adult client. C. Oral temperature of 38.2° C (100.76° F) Rationale: An oral temperature of 38.2° C (100.76° F) represents a slight temperature elevation in an adult client and may indicate mild postoperative dehydration. D. An urge to void despite having an indwelling urinary catheter Rationale: Clients who undergo TURP procedures have a catheter in place postoperatively to allow drainage and irrigation of the bladder. Traction is applied to the catheter causing pressure on the bladder neck. This, along with the larger diameter of the catheter, causes a constant sensation of needing to urinate. 50. A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? A. White blood cell (WBC) count Rationale: WBC count is often done to monitor response to the treatment of infections, but it is not effective in monitoring the response to RA treatment. B. Rheumatoid factor (RF) Rationale: RF is helpful in diagnosing rheumatoid arthritis, but the levels do not always correlate with the severity of the disease activity. It will not accurately reflect the effectiveness of the aspirin Page 26 therapy. C. Antinuclear antibody (ANA) Rationale: ANAs are frequently present in clients who have systemic lupus erythematosus and other autoimmune disorders such as rheumatoid arthritis and scleroderma. Although this client's ANA is likely to be positive (indicating autoimmune disease), it is not reflective of the effectiveness of the aspirin therapy. D. Erythrocyte sedimentation rate (ESR) Rationale: Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases. 51. A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? A. Monitor sensory perception of the lower extremities. Rationale: The nurse should perform neurologic assessments focusing on sensory perception of the lower extremities every 4 hr. Any decrease in sensation by the client requires immediate notification of the provider. B. Assist the client into a knee-chest position to manage postoperative discomfort. Rationale: A client who is postoperative following a laminectomy needs to maintain a straight back. C. Maintain strict bed rest for the first 48 hr postoperative. Rationale: The nurse should assist the client to get out of bed with assistance in the evening following surgery. D. Position the client in a high-Fowler's position if clear drainage is noted on the dressing. Rationale: The nurse should place a client who has clear drainage on the surgical dressing in a supine position and notify the provider immediately. 52. A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Medicate the client for pain. Rationale: The nurse should assess and treat the client for pain because uncontrolled pain has deleterious effects systemically, e.g., increased pulse and blood pressure, increased oxygen demand, and delayed healing. Medicating the client for pain is an appropriate nursing action, but another action is the priority. B. Instruct the client on use of crutches. Rationale: It will be important for the nurse to instruct the client on the proper use of crutches to avoid Page 27 further injury; however, another action is the priority. C. Perform neurovascular checks of the extremities. Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage