ATI Comfort Nutrition Elimination Exam; Complete Questions and Answers_ Answered 100% correct, updated 2025.

ATI QUESTIONS 1430 Comfort Nutrition Elimination COMFORT / 78S6667D54 1. A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?  Lemon-lime soda o The nurse should recommend lemon-lime soda because it does not contain caffeine. Caffeine acts as a CNS stimulant and can interfere with sleep.  Brewed iced tea o The nurse should not recommend brewed iced tea because it contains caffeine. Caffeine acts as a CNS stimulant and can interfere with sleep.  Diet cola o The nurse should not recommend diet cola because it contains caffeine. Caffeine acts as a CNS stimulant and can interfere with sleep.  Chocolate milk o The nurse should not recommend chocolate milk because it contains caffeine. Caffeine acts as a CNS stimulant and can interfere with sleep. 2. A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain?  Prone with her arms raised above her head o The nurse should instruct the client to avoid the prone position as it increases stress on the muscles and tissues of the lower back and accentuates lordosis.  Semi-Fowler's with a pillow under her knees o Low back pain is an expected manifestation of a herniated lumbar disc. Sitting partially upright with knee flexion helps to relax the lumbar muscles and takes pressure off the spinal nerve root, which promotes comfort for the client.  Supine with her arms elevated on pillows o The nurse should instruct the client to avoid this position as it increases stress on the muscles and tissues of the lower back and can irritate the spinal nerve roots, increasing neuropathic pain.  Supine with the head of the bed elevated to 15°o The nurse should position a client who has an injury to the thoracolumbar spine in a low-Fowler's position at an elevation of no more than 15°. However, this position will increase discomfort for a client who has a herniated lumbar disc. 3. A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?  "I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it." o Two nurses are required to witness the wasting of a narcotic and then sign the narcotic record. The nurse should not ask another nurse to sign the narcotic record if the nurse did not witness wasting the narcotic.  "I noted that my client pushed the PCA button six times in the last hour, and the PCA lockout is set for 10 minutes." o The client is using the PCA effectively and no further action is required by the charge nurse.  "I gave my client a bolus dose of morphine when I initiated the PCA pump." o PCA prescriptions can begin with a bolus dose in order to establish a blood level of the opioid.  "I told the client's family that they must not push the PCA button for the client." o The client should press the PCA button to reduce the risk for over sedation. 4. A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?  Tennis o The physical motions of playing tennis can strain back muscles and worsen the client’s pain.  Canoeing o The physical motions of playing tennis can strain back muscles and worsen the client’s pain.  Swimming o Some exercises, such as swimming and walking, can help clients who have low back pain because they strengthen back muscles  Rowing o The physical motions of playing tennis can strain back muscles and worsen the client’s pain. 5.A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?  Apply the bag for 30 min at a timeo The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects  Reapply the bag 30 min after removing it o After removing the ice bag, the nurse should not reapply it any sooner than 1 hr later.  Allow room for some air inside the bag. o The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag. Air can block the conduction of cold to the injury.  Place the bag directly on the skin. o The nurse should place a towel, the bag's cover material, or a pillowcase between the ice bag and the client's skin. 6. A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?  "I will call for pain medication before the previous dose wears off. o The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe  "I will call for pain medication as my pain starts to increase again." o The client should call for pain medication before the pain starts to increase.  "I will wait for you to evaluate my pain before asking for more medication." o The client should not wait for the nurse to initiate an evaluation to control postoperative pain.  "I will ask for less medication to avoid addiction." o The client should receive enough pain medication to control postoperative pain safely. 7. A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?  Administer a bolus of medication. o The nurse should administer a bolus of medication to achieve a more rapid desired outcome for pain control; however, there is another action the nurse should take first.  Check the display on the PCA pump. o The first action the nurse should take using the nursing process is to assess the client; therefore, the nurse should assess the display on the PCA pump to determine the amount of medication administered. Some clients are fearful of developing an addiction to narcotics and may be reluctant to use the PCA.  Obtain an order for another pain medication for breakthrough pain o The nurse should obtain an order for another pain medication for breakthrough pain if needed; however, there is another action the nurse should take first.  Encourage the client to administer a demand dose.o The nurse should encourage the client to administer a demand dose of medication to increase the blood level of medication for pain control; however, there is another action the nurse should take first. 8.A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?  Take the medication with an aspirin to increase effectiveness. o Ibuprofen decreases the antiplatelet effect of aspirin when the medications are taken together. The nurse should instruct the client to take aspirin 2 hr before taking the ibuprofen.  Take the medication with food o To minimize gastric irritation, the nurse should instruct the client to take ibuprofen with food, water, or milk.  Taking the maximum dose will offer stroke prevention. o Unlike aspirin, ibuprofen and other NSAIDs increase the risk of stroke and myocardial infarction. The nurse should instruct the client to take the lowest effective dose.  Sustained-release forms may be crushed for easier administration. o Sustained-release medications are designed to release the dosage throughout the day, allowing for a reduction in the frequency of dosing. If a sustained-release medication is crushed, it destroys the coatings that surround the drug particles that control the rate of release. The nurse should instruct the client that sustained-release medications should not be crushed. 9. A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?  "Next time you think he needs more medication, call me and I'll push the button." o The nurse should administer a PRN or around-the-clock dosing if the client is having breakthrough pain, but should not push the client’s PCA button.  "It's a good idea to help make sure your husband can sleep comfortably." o The nurse should determine with the client’s awareness if there is breakthrough pain that may require more pain medication.  "Why do you think your husband needs more medication when he is asleep?" o The nurse’s goal is to educate the client’s partner. Asking “why” questions can make the partner defensive.  "Your husband should decide when more medication is needed. o The nurse should explain to the client’s partner that the client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump. 10.A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?  Expect ringing in your ears. o The client should report ringing in the ears because this is a manifestation of ototoxicity. Take the medication with food. o To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.  Store the medication in the refrigerator. o The client should store ibuprofen at room temperature.  Monitor for weight loss. o The client should monitor for weight gain, which is a manifestation of nephrotoxicity and edema. 11. A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?  Diarrhea o Opioids may decrease intestinal motility, which can lead to constipation.  Heartburn o Opioids may cause nausea, vomiting, and anorexia, but not heartburn.  Hiccups o Opioids may cause nausea, vomiting, and anorexia, but not hiccups.  Orthostatic hypotension o The nurse should monitor the client for orthostatic hypotension and encourage the client to rise or change position slowly to decrease the risk for falls. 12. A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?  "Use the pain scale to determine if you need to self-administer." o The nurse should instruct the client to use the pain scale to rate his pain level before self-administering a bolus dose. A bolus dose is the amount of medication received when the client self-administers the opioid. The nurse should monitor the client to determine is the bolus dose is too high or low or if the interval is too short or too long.  "Ask a family member to push the patient-control button when the client is sleeping." o The client is the only person authorized to self-administer using the PCA pump. The provider may assign a healthcare proxy to administer the bolus medication if the client is unable to push the button.  "There is a 30 minute lock-out limit programmed on your PCA pump." o The nurse should instruct the client that the PCA pump lock-out limit is programmed for 1 to 4 hr to prevent overdose. This safety feature is one means of preventing an overdose, as the client cannot self-administer another dose if the maximum doses of medication are given during that time period.  "Several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before lock-out." o The nurse should instruct the client that one bolus dose of self-administered medication is infused within a pre-set 5 min timeframe before lockout. NUTRITION / 25S5355D55 1. A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?  A client who has a body fat of 22% o A female client who has body fat of 22% is within the expected range of 18% to 32% body fat.  A client who has a BMI of 28 o A female client who has a BMI of 28 is classified as overweight.  A client who has a waist circumference of 81.3 cm (32 in)o A female client who has a waist circumference greater than 88.9 cm (35 in) is classified as obese.  A client who weighs 28% above ideal body weight o MY ANSFor a female client, obesity is classified as a weight 20% greater than ideal weight. A client whose weight is 28% above ideal body weight is classified as obese. 2. A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?  Dobutamine o The nurse should administer dobutamine, a cardiac stimulant used when cardiac decompensation occurs due to anaphylactic shock; however, it is not the first medication the nurse should administer.  Methylprednisolone o The nurse should administer methylprednisolone, a corticosteroid, to decrease itching and severe rash; however, it is not the first medication the nurse should administer.  Furosemide o The nurse should administer furosemide, a loop diuretic, to improve renal profusion during an anaphylactic crisis; however, it is not the first medication the nurse should administer.  Epinephrine o ANThe priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine, a bronchodilator and vasopressor used for allergic reactions to reverse severe manifestations of anaphylactic shock. 3. A nurse is teaching a client who is obese about orlistat. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?  Drowsiness o Insomnia is an adverse effect of orlistat.  Constipation o Diarrhea is an adverse effect of orlistat, because of the GI tract’s decreased absorption of fat.  Oily fecal spottingMY ANSWER o Oily fecal spotting is an adverse effect of orlistat, because of the GI tract’s decreased absorption of fat.  Dark-colored stools o Light-colored stool, which may indicate possible liver damage, is an adverse effect of orlistat and should notify the provider. 4. A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight?  A Female client who has a body mass index of 24 o A female client who has a BMI of 24 has a healthy weight.  A male client who has a body mass index of 29 o A client who has a BMI of 25 to 29.9 is classified as overweight.  A female client who has a waist circumference of 101.6 cm (40 in) o A waist circumference for women of greater than 88.9 cm (35 in) is classified as obese. A male client who has a waist circumference of 96.52 cm (38 in) o A waist circumference for men of greater than 101.6 cm (40 in) is classified as obese. 5. A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?  "I will take my dose of orlistat every morning an hour before breakfast." o Orlistat, a lipase inhibitor, is used as an aid to help clients who are morbidly obese to lose weight. Orlistat prevents the absorption of some of the fat in the client's dietary intake at each meal. Therefore, the client should take the medication 3 times daily, during or within 1 hr after the meal.  "I will eat a no-fat diet to prevent side effects from the medication." o Consuming too little fat may lead to the client not getting enough nutrients, especially fat-soluble vitamins, from the diet. Instead, the client should eat a well-balanced, low-calorie, nutritious diet with approximately 30% of calories consisting of fat calories.  "I will stop taking orlistat and call my doctor if my urine gets darker in color." o Orlistat can cause severe liver damage; therefore, the client should be taught manifestations of liverdamage, including dark-colored urine, lightcolored stools, jaundice, anorexia, vomiting, and fatigue.  "I will feel less hungry during meals while I am taking orlistat." o Orlistat works by preventing absorption of dietary fat and is not an appetite suppressant. 6. A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?  Creatine kinase o Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.  Troponin o Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.  Total bilirubin o Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.  Albumin o A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. 7.A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?  Hypoactive bowel sounds in two quadrants o Hypoactive bowel sounds are an expected finding postoperatively and do not indicate peristalsis has returned.  Request for a cup of tea and some toast o The client's request for fluid and food does not indicate peristalsis has returned.  Passage of flatuso Passing flatus and belching indicate the return of peristaltic activity.  Abdominal distention o Abdominal distention is more likely to indicate the absence rather than the return of peristalsis. 8. A nurse is completing a medication history for a client who reports using over-thecounter calcium carbonate antacid. Which of the following recommendations should the nurse make about taking this medication?  Decrease bulk in the diet to counteract the adverse effect of diarrhea. o The major adverse effect of calcium carbonate is constipation. The nurse should recommend the client increase bulk in the diet  Take the medication with dairy products to increase absorption. o Taking calcium carbonate with milk predisposes the client to milk alkali syndrome, which is characterized by headache, confusion, nausea, vomiting, alkalosis, and hypercalcemia.  Reduce sodium intake. o Clients who take aluminum hydroxide, not calcium carbonate, antacids should be advised against excessive sodium intake in the diet.  Drink a glass of water after taking the medication o Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium carbonate may also be used as an antacid to relieve heartburn, acid indigestion, and stomach upset. The client should drink a full glass of water after taking an antacid to enhance its effectiveness. 9. A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?  Yogurt o Yogurt is allowed on a full liquid diet, not a clear liquid diet.  Popsicle o Popsicles are allowed on a clear liquid diet.  Gelatin o Gelatin is allowed on a clear liquid diet.  Broth o Broth is allowed on a clear liquid diet. 10. A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?  Assess the client's level of consciousness. o The nurse should assess and monitor the client’s level of consciousness as anaphylaxis causes widespread vasodilation and anaphylactic shock may develop. However, this is not the priority intervention action when taking the airway, breathing, circulation (ABC) approach to client care. Administer epinephrine. o The nurseshould administer epinephrine as this medication causes vasoconstriction, bronchodilation, and improves cardiac output. However, this is not the priority action when taking the airway, breathing, circulation (ABC) approach to client care.  Auscultate for wheezing o When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.  Monitor for hypotension. o The nurse should monitor for hypotension because the anaphylactic reaction causes systemic vasodilation placing the client at risk for hypovolemic shock. However, another action is the priority when taking the airway, breathing, circulation (ABC) approach to client care. 11. A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?  Aspirate the client's stomach contents o The first action the nurse should take using the nursing process is to assess the residual stomach contents. The nurse should measure the stomach contents to assess whether the feeding is being absorbed by the client. The nurse might delay the tube feeding for a high residual to reduce the risk of aspiration.  Hang the feeding bag 30 cm (12 in) above the client. o The nurse should hang the feeding bag 30 cm (12 in) above the client to control the rate of infusion and reduce the risk for abdominal cramping; however, there is another action the nurse should take first.  Label the feeding bag with the date and time of the start of the feeding. o The nurse should label the feeding bag with the date and time to reduce the risk for bacterial growth; however, there is another action the nurse should take first.  Warm the feeding to room temperature. o The nurse should warm the feeding to room temperature to reduce the risk for abdominal cramping; however, there is another action the nurse should take first. Elimination 1. A nurse is teaching a client who has benign prostatic hypertrophy and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching?  Avoid drinking grapefruit juice when taking this medication. o Finasteride can be taken with or without food and does not interact adversely with grapefruit juice.  Expect to see a response from the medication within one week. o The client may not respond to the medication for 6 to 12 months.  Decreased libido is an adverse effect of the medication.o The nurse should include in the teaching that the client may experience decreased libido as an adverse effect of the medication because of the androgenic effect on the prostate.  PSA levels will increase while taking this medication. o The client’s PSA levels will decrease when taking the medication because of the androgenic effect on the prostate. 2. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?  Assist the client to the bathroom every 2 hr. o By assisting the client to the bathroom every 1 to 3 hr during waking hours and every 4 to 6 hr during sleeping hours, the nurse establishes a regular pattern of toileting and a physical pattern that promotes bladder control.  Restrict oral fluid intake during waking hours. o Adequate fluid intake that does not include caffeine can help a client who is in a bladder-retraining program. The fluid acts to increase the flow to the bladder and ensures bladder expansion while decreasing the likelihood of a urinary tract infection, which could delay bladder retraining. The client should restrict fluid intake a few hours before bedtime to reduce nocturia.  Encourage the client to hold her breath when feeling the urge to urinate. o The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate.  Provide adult diapers until bladder retraining is successful. o The nurse should avoid providing diapers because doing so sends a message that incontinence is allowable. 3. A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?  Pale pink o The client should expect to pass some small clots and tissue in his urine for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery, around the time of discharge, his urine should be clear yellow.  Bright yellow o The nurse should warn the client that if his urine is bright yellow, he may need to increase his fluid intake. He should drink at least 2,000 to 2,500 mL of fluid daily.  Bright red o The nurse should warn the client that if his urine is bright red, he should call the provider immediately, as this indicates active bleeding.  Dark amber o The nurse should warn the client that if his urine is dark amber, he needs to increase his fluid intake. He should drink at least 2,000 to 2, 500 mL of fluid daily. 4. A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include?  Take this medication with an antacid. o The client should not take an antacid within 2 hr of this medication to increase absorption.  Monitor for tendon pain.o Ciprofloxacin can cause tendinitis and tendon rupture. The client should monitor and report tendon pain or inflammation.  Drink 1,000 milliliters of fluid daily. o The client should drink 3,000 mL of fluid daily to reduce the risk for crystallization of ciprofloxacin and to dilute urine.  Expect urine to turn dark orange. o Phenazopyridine turns urine red-orange. 5.A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record?  Enuresis o The nurse should not document enuresis, which is involuntary urination.  Anuria o The nurse should not document anuria, which is a total urine output of less than 100 mL in 24 hr.  Nocturia o The nurse should not document nocturia, which is frequency of urination during the night.  Oliguria o The nurse should document the client has oliguria, which is urine output between 100 mL and 400 mL of urine in 24 hr. 6. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)  Add the amount of bladder irrigation to the total output. o The irrigation solution that should be used is sterile normal saline, unless otherwise directed by the surgeon. The amount of solution should be subtracted from the total output amount. For example, if the total drainage output is 2,500 mL and the amount of irrigation is 1,000 mL, subtract 1,000 from 2,500 and record 1,500 mL as the total urine output.  Use sterile technique when preparing the irrigation solution. o Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. These clients should also be observed closely for manifestations of infection, such as fever and elevated WBC.  Ensure the drainage tubing is patent and without obstruction. o For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury.  Contact the surgeon if the client reports a continual need to void. o The catheter used following a TURP is large and is pulled taut and secured to the client’s leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client may experience a continual need to void.  Notify the surgeon if the urine is bright red in appearance or has large clots. o It is normal to see a few small blood clots and pink tinged drainage, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding and should be reported to the surgeon. 7. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply).  Relief of urinary retention o Valid indications for urinary catheterization include urinary retention, bladder distention, management of urinary eliminationfor clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.  Convenience for the nursing staff or the client's family o Performing an invasive procedure for convenience is unacceptable. Valid indications for urinary catheterization include management of urinary elimination for clients who have spinal cord injuries and prevention of urethral obstruction from blood clots following genitourinary surgery.  Measurement of residual urine after urination o Valid indications for urinary catheterization include measurement of residual urine after urination, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.  Routine acquisition of a urine specimen o The nurse can obtain routine urine specimens by noninvasive methods. Valid indications for urinary catheterization include urinary retention, bladder distention, and prevention of urethral obstruction from blood clots following genitourinary surgery.  An open perineal wound o Valid indications for urinary catheterization include preventing irritation of wounds and rashes from urine, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery. 8. 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?  Notify the provider. o 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.  Check the tubing for kinks. o 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.  Adjust the rate of the bladder irrigant. o 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.  Irrigate the catheter. o The nurse may need to irrigate the catheter to check for an internal obstruction; however, the nurse should use a less restrictive intervention first. 9. A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?  "If the medicine causes an upset stomach, take an antacid at the same time." o Ciprofloxacin is best absorbed on an empty stomach with a full glass of water. Antacids containing either magnesium or aluminum can decrease the absorptionof ciprofloxacin. If an antacid is taken, the nurse should instruct the client to wait at least 2 hr after administering the ciprofloxacin.  "Limit your daily fluid intake while taking this medication." o The nurse should instruct the client that ciprofloxacin is a fluoroquinolone antibiotic used in the treatment of mild to severe infections. It is excreted primarily via the kidneys, and drinking extra fluids will reduce the risk of crystallization in the kidneys.  "This medication can cause photophobia, so be sure to wear sunglasses outdoors." o Ciprofloxacin can cause phototoxicity, putting the client at risk for extreme sunburn from minimal sun exposure. The client should wear protective clothing when out in the sun. Photophobia is eye sensitivity to light.  "You should report any tendon discomfort you experience while taking this medication. o The nurse should instruct the client to report any tendon discomfort as well as swelling or inflammation of the tendons due to the risk of tendon rupture. 10. A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?  Remind the client to tell the nurse when he has to urinate. o It is unlikely that a client who has dementia will remember to tell the nurse when he needs to urinate.  Use adult diapers to prevent frequent clothing changes. o Adult diapers might contain the urine, but they will not help to manage the behavioral aspects of incontinence.  Take the client to the bathroom every 2 hr. o By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.  Request a prescription for an indwelling urinary catheter. o Because of the complications invasive procedures like catheterization can cause, the nurse should consider them a last resort. 11. A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)  "Your provider might prescribe anticholinergic medications." o Anticholinergic medications suppress bladder contractions and increase bladder capacity.  "You should limit fluids in the evening." o Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep.  "You should restrict your intake of caffeine." o The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.  "You might require intermittent urinary catheterization." o Intermittent urinary catheterization is used as a treatment for reflex incontinence.  "You might require an anterior vaginal repair." o An anterior vaginal repair, or colporrhaphy, is a surgical procedure for the treatment of stress incontinence.1128 Exam Gas Exchange Immunity 1128 GAS EXCHANGE / 36S5596667 1. A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?  Respiratory acidosis o Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.  Respiratory alkalosis o Alkalosis occurs when there is an imbalance in the amount or strength of the bases. In cases of respiratory alkalosis, this occurs because of an excessive loss of carbon dioxide through hyperventilation. It can occur in clients as a response to fear, anxiety or pain, from a fever or salicylate (aspirin) overdose.  Metabolic acidosis o Metabolic acidosis results due to an increase in the amount of acid or a decrease in the amount of base available. It is seen in starvation, diabetic ketoacidosis, renal failure, dehydration, and diarrhea.  Metabolic alkalosis o Metabolic alkalosis results from an increase in the amount of bases seen in massive blood transfusion, or the administration of sodium bicarbonate, or a bicarbonate containing antacid. It can also occur related to an acid deficit, seen with prolonged vomiting, the use of thiazide diuretics, or prolonged gastric suctioning. 2. A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority?  Provide the client with supplemental oxygen at 5 L/min via facemask. o The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to provide supplemental oxygen at 5 L/min via simple facemask to promote effective gas exchange and tissue perfusion and to prevent rebreathing of exhaled air. The client is exhibiting signs of respiratory distress, such as dyspnea at rest, crackles, and anxiousness. Therefore, this is the nurse's priority intervention because it would helps manage hypoxia related to pulmonary edema.  Place the client in high-Fowler's position with their legs in a dependent position. o The nurse should place the client in high-Fowler's position with their legs in a dependent position to decrease venous blood return to the heart. However, there is another intervention that is the nurse's priority.  Give the client sublingual nitroglycerin.o The nurse should give the client sublingual nitroglycerin to decrease the preload and afterload. However, there is another intervention that is the nurse's priority.  Administer morphine sulfate IV. o The nurse should administer morphine sulfate IV to decrease the preload and afterload and decrease the client's anxiety. However, there is another intervention that is the nurse's priority. 3.A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?  Widened QRS complexes o A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block.  Hyperactive deep tendon reflexes o A client who has respiratory acidosis is more likely to have reduced muscle tone and hypoactive deep tendon reflexes due to hyperkalemia.  Bounding peripheral pulses o A client who has respiratory acidosis is more likely to have ready peripheral pulses which are difficult to palpate.  Warm, flushed skin o A client who has respiratory acidosis is more likely to have pale to cyanotic, dry skin. A client who has metabolic acidosis is likely to have warm, flushed dry skin. 4.A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?  Hyperinsulinemia o High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.  Increased deposits of fat in the chest and shoulder area o Increased fat deposits in the chest and shoulder area increase the risk of shoulder dystocia at delivery.  Brachial plexus injury o A brachial plexus injury causes the arm to hang limply at the newborn’s side. It is typically the result of a difficulty delivery.  Increased blood viscosity o Increased blood viscosity is due to polycythemia, which increases the risk of developing hyperbilirubinemia. 5. A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?  Respiratory alkalosis o The nurse should anticipate the client's arterial blood gasses will reveal respiratory acidosis because there is increased arterial carbon dioxide.  Increased anteroposterior diameter of the chest o The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.  Oxygen saturation level 96% o This oxygen saturation level is within the expected reference range. The nurse should anticipate a decreased oxygen saturation level. Petechiae on chest o The nurse should anticipate petechiae on the chest and the abdomen for a client who has pulmonary embolism. 6. 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  Respiratory acidosis o 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).  Metabolic acidosis o 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).  Metabolic alkalosis o 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 anHCO3 level that is higher than the normal reference range (35 – 45 mm Hg).  Respiratory alkalosis o 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) 7.A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acidbase imbalances?  Metabolic acidosis o With uncompensated metabolic acidosis, the pH is less than 7.35 and the PaCO2 is less than 35 mm Hg or within the expected reference range.  Metabolic alkalosis o With uncompensated metabolic alkalosis, the pH is greater than 7.45 and the PaCO2 is greater than 45 mm Hg or within the expected reference range.  Respiratory acidosis o With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.  Respiratory alkalosis o With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO2 is less than 45 mm Hg. 8. A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?  HCO3- 30 mEq/L o This laboratory value is expected for a client who has metabolic alkalosis.  PaCO2 50 mm Hg o This laboratory value is an expected finding for a client who has respiratory acidosis.  pH 7.45 o This laboratory value is within the expected reference range.  Potassium 3.3 mEq/L o This laboratory value is expected for a client who has metabolic alkalosis. IMMUNITY / 24S6564F481. A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?  Administer the medication with food." o Administering diphenhydramine with food might minimize gastrointestinal effects, but will not relieve dry mouth.  "Chew on sugarless gum or suck on hard, sour candies. o Clients who report dry mouth can get the most effective relief by sucking on hard candies (especially the sour varieties that stimulate salivation), chewing gum, or rinsing the mouth frequently. It is the local effect of these actions that provides comfort to the client.  "Place a humidifier at your bedside every evening." o This action might help to ease the work of breathing when the client has congestion, but it will not relieve the manifestation of dry mouth.  "Discontinue the medication and notify your provider." o It is not necessary for the client to discontinue the use of diphenhydramine for dry mouth. The nurse should inform the client to notify the provider of any confusion, sedation, or hypotension. 2. A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?  Urticaria o For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as diphenhydramine prior to the transfusion might prevent future reactions. Allergic reactions typically include urticaria (hives).  Fever o An antihistamine will not prevent a febrile, non-hemolytic reaction to a blood transfusion. A possible preventive measure is transfusing leucocytepoor blood products to avoid sensitization to the donor's WBC.  Fluid overload o An antihistamine will not prevent fluid overload. Transfusing the blood product slowly and not exceeding the volume that is necessary can reduce this risk.  Hemolysis o An antihistamine will not prevent hemolysis, which results from incompatibility between the donor and the recipient. 3.A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?  Assess the client's level of consciousness. o The nurse should assess and monitor the client’s level of consciousness as anaphylaxis causes widespread vasodilation and anaphylactic shock may develop. However, this is not the priority intervention action when taking the airway, breathing, circulation (ABC) approach to client care.  Administer epinephrine. o The nurseshould administer epinephrine as this medication causes vasoconstriction, bronchodilation, and improves cardiac output. However, this is not the priority action when taking the airway, breathing, circulation (ABC) approach to client care.  Auscultate for wheezing o When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status.Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.  Monitor for hypotension. o The nurse should monitor for hypotension because the anaphylactic reaction causes systemic vasodilation placing the client at risk for hypovolemic shock. However, another action is the priority when taking the airway, breathing, circulation (ABC) approach to client care. 4. A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?  Pruritus o An allergic reaction is an immune response that can manifest as pruritus and urticaria and can progress to anaphylaxis.  Diarrhea o Gastrointestinal side effects of oxacillin can include nausea, vomiting, flatulence, and diarrhea. Diarrhea is a manifestation of pseudomembranous colitis.  Dark urine o Dark urine is a manifestation of dehydration or hepatic dysfunction.  Fever o A fever is a manifestation of the infection or it can indicate bone marrow depression. 5. A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse give?  "Gradually decrease the dose once tolerance to the effect is reached." o A nurse should not instruct a client to change the prescribed dose of a medication.  "Distribute the doses evenly throughout the day." o Taking the medication throughout the day will not reduce the sedative effect.  "Take most of the daily dose at bedtime. o Taking most of the dose at bedtime will allow the client to obtain the benefit of maximum relief of manifestations and rest without itching.  "Take the medication with meals." o Taking the medication with meals does not alter the sedative effect. 6. A nurse is caring for a client who received an injection of penicillin G procaine. The client begins to experience dyspnea and tongue swelling. Which of the following actions should the nurse perform first?  Obtain intravenous fluids for administration. o The nurse should begin administration of IV fluids to correct hypotension that may occur during an anaphylactic response; however, another action is the priority.  Record the observed data in medical record. o The nurse should record the observed data to document the event; however, another action is the priority.  Deliver a dose of aminophylline by inhalation. o The nurse should administer a bronchodilator to facilitate breathing; however, another action is the priority.  Administer epinephrine subcutaneouslyo The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer epinephrine. The effect of the epinephrine is to act on adrenergic receptors, causing bronchodilation of the lungs and an elevation of blood pressure. By stimulating both alpha and beta adrenergic receptors to cause these effects, it accomplishes more of the goals of treatment of anaphylaxis than any other single therapy. 7.A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention?  Insert an IV line. o The nurse should insert an IV line to provide fluids and medications. However, it is not the priority action when following the nursing process approach to client care.  Count the respiratory rate o Checking the client’s respiratory status is the priority action when following the nursing process approach to client care.  Administer oxygen. o The nurse should administer oxygen to the client using a high-flow, non-rebreather mask to prevent hypoxia. However, it is not the priority action when following the nursing process approach to client care.  Prepare equipment for intubation. o Preparing equipment for intubation ensures the client will maintain an open airway in the event of respiratory failure. However, it is not the priority action when following the nursing process approach to client care. 8.A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions? Move the nursing actions into the box on the right, placing them in the selected order of performance. All steps must be used.)  Assess clients airway  Call rapid response team  Apply high-flow oxygen  Initiate IV access  Administer IV epinephrine  Administer IV antihistamines 9.A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?  Urticaria o The nurse should administer an antihistamine or corticosteroid to minimize the client's itching or skin inflammation; however, there is another finding the nurse should address first.  Stridor o MY ANSWERWhen using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.  Vomiting o The nurse should administer an antiemetic medication for the client; however, there is another finding the nurse should address first.  Hypotension o The nurse should raise the client's feet and legs to promote venous return of blood to the torso and maintain vital organs perfusion; however, there is another finding the nurse should address first.10.A nurse is assessing a client who has a history of HIV with phagocytic dysfunction. The nurse should monitor this client for which of the following conditions?  Dehydration o The nurse does not need to monitor the client for dehydration.  Fungal infection o The nurse should monitor the client for fungal infections due to the impairment of the phagocytic cells. Fungal and bacterial infections are the primary results of the dysfunction.  Compartment syndrome o The nurse does not need to monitor the client for compartment syndrome.  Pleural effusion o The nurse does not need to monitor the client for pleural effusion.